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Tax Codification - Factors and Instructions Presented by the American Academy of Actuaries Life-Risk Based Capital Committee’s Codification Subgroup to the National Association of Insurance Commissioners Life Risk-Based Capital Working Group June 2001 – New Orleans, LA The American Academy of Actuaries is the public policy organization for actuaries practicing in all specialties within the United States. A major purpose of the Academy is to act as the public information organization for the profession. The Academy is nonpartisan and assists the public policy process through the presentation of clear and objective actuarial analysis. The Academy regularly prepares testimony for Congress, provides information to federal elected officials, comments on proposed federal regulations, and works closely with state officials on issues related to insurance. The Academy also develops and upholds actuarial standards of conduct, qualification and practice and the Code of Professional Conduct for all actuaries practicing in the United States. Codification Subgroup James F. Reiskytl, F.S.A., M.A.A.A., Chair Joseph L. Dunn, F.S.A., M.A.A.A. Robert F. Herbert, Jr., F.S.A., M.A.A.A. Mark C. Rowley, F.S.A.,M.A.A.A. Harold Summer, F.S.A., M.A.A.A.

William C. Weller, F.S.A., M.A.A.A. Bill Wilton, F.S.A., M.A.A.A. Michael L. Zurcher, F.S.A., M.A.A.A.


Summary: The following spreadsheets update the RBC instructions and the disc to implement these recommendations. One adjusts Total Adjusted Capital (TAC) to reflect codification including Deferred Tax Assets and Deferred Tax Liabilities in the TAC. The other adjusts the RBC calculation. The latter includes the new separate tax factor calculation required to calculate RBC. The spreadsheets also provide instructions to implement the new Tax Sensitivity Test--showing results on a pre-tax basis that may in turn be adjusted by the NAIC’s LRBC Working Group to vary the degree of tax recognition appropriate for the specific company that potentially is weakly capitalized.


CALCULATION OF TOTAL ADJUSTED CAPITAL -1 Annual Statement Source

(2)

Statement Value

Factor

Adjusted Capital

Company Amounts (1)

Capital and Surplus

Page 3 Column 1 Line 38

X 1.000

=

(2) (3)

Asset Valuation Reserve

Page 3 Column 1 Line 24.1

X 1.000

=

Dividends Apportioned for Payment

Page 3 Column 1 Line 7.1

X 0.500

=

(4)

Dividends Not Yet Apportioned

Page 3 Column 1 Line 7.2

X 0.500

=

Life Subsidiary Company Amounts† (5)

Asset Valuation Reserve

Subsidiaries' Annual Statement Page 3 Column 1 Line 24.1‡

X 1.000

=

(6)

Dividend Liability

Subsidiaries' Annual Statement Page 3 Column 1 Line 7.1 + Line 7.2‡

X 0.500

=

Included in Subsidiaries' Annual Statement Page 3 Column 1 Line 1 + 2‡

X 1.000

=

Property and Casualty Amounts (7)

Non-Tabular discount

(8)

Total Adjusted Capital Before Capital NotesSum of Lines (1) through (6) less Line (7) Credit for Capital Notes

(9.1)

Surplus Notes

Page 3 Column 1 Line 32

(9.2)

Limitation on Capital Notes

0.5 x [Line (8) - Line (9.1)] - Line (9.2), but not less than 0

(9.3)

Capital Notes Before Limitation

LR026 Capital Notes Before Limitation Column (5) Line (18)

(9.4)

Credit for Capital Notes

Lesser of Column (1) Line (9.2) or Line (9.3)

(10)

Total Adjusted Capital (pre-tax)

Line (8) + Line (9.4)

L(11.1) L(11.2)

DTA Value for Company DTL Value for Company

Page 2, Line 19 (insert) Page 3, Line 8 (insert)

x x

0 = 0 =

L(12.1) L(12.2)

DTA Value for Subsidiaries DTL Value for Subsidiaries

From Company Records From Company Records

x x

0 = 0 =

L(13)

Total Adjusted Capital (post-tax) Line (10)+(11.1)+(11.2)+(12.1)+(12.2)


CALCULATION OF AUTHORIZED CONTROL LEVEL RISK-BASED CAPITAL (1) RBC Source Asset Risk - Affiliated Amounts (C-0) (1)

Affiliated US Property-Casualty Insurers Directly Owned

LR033 Summary for Affiliated Investments Column (4) Line (1)

(2)

Affiliated US Life Insurers Directly Owned

LR033 Summary for Affiliated Investments Column (4) Line (2)

(3)

Affiliated US Property-Casualty Insurers Indirectly Owned

LR033 Summary for Affiliated Investments Column (4) Line (3)

(4)

Affiliated US Life Insurers Indirectly Owned

LR033 Summary for Affiliated Investments Column (4) Line (4)

(5)

Affiliated Alien Life Insurers - Canadian

LR033 Summary for Affiliated Investments Column (4) Line (7)

(6)

Affiliated Alien Life Insurers - All Others

LR033 Summary for Affiliated Investments Column (4) Line (8)

(7)

Off-Balance Sheet Items

LR014 Off-Balance Sheet Items Column (2) Line (23)

(8)

Total (C-0)

Sum of Lines (1) through (7)

Asset Risk - All Other (C-1) (9)

Bonds after Size Factor

LR002 Bonds Column (2) Line (26)

(10)

Mortgages (including past due and unpaid taxes)

LR004 Mortgages Column (6) Line (22)

(11)

Unaffiliated Preferred Stock and Common Stock

LR005 Unaffiliated Preferred and Common Stock Column (4) Line (17)

(12)

Affiliated Preferred Stock and Common Stock - Investment Subsidiaries

LR033 Summary for Affiliated Investments Column (4) Line (5)

(13)

Affiliated Preferred Stock and Common Stock - Holding Company in Excess of

LR033 Summary for Affiliated Investments Column (4) Line (6)

Indirect Subsidiaries (14)

Affiliated Preferred Stock and Common Stock - Parent

LR033 Summary for Affiliated Investments Column (4) Line (9)

(15)

Affiliated Preferred Stock and Common Stock - Property and Casualty Insurers not

LR033 Summary for Affiliated Investments Column (4) Line (10)

Subject to Risk-Based Capital (16)

Affiliated Preferred Stock and Common Stock - Life Insurers not Subject to Risk-Based LR033 Summary for Affiliated Investments Column (4) Line (11) Capital LR033 Summary for Affiliated Investments Column (4) Line (12)

(17)

Affiliated Preferred Stock and Common Stock - All Other

(18)

Affiliated Preferred Stock and Common Stock - Publicly Traded Insurers Held at LR033 Summary for Affiliated Investments Column (4) Line (13)

Requirement


Market Value (excess of statement value over book value) (19)

Separate Accounts with Guarantees

LR006 Separate Accounts Column (2) Line (7)

(20)

Synthetic GIC's (C-1)

LR006 Separate Accounts Column (2) Line (8)

(21)

Surplus in Non-Guaranteed Separate Accounts

LR006 Separate Accounts Column (2) Line (13)

(22)

Real Estate (gross of encumbrances)

LR007 Real Estate Column (3) Line (16)

(23)

Schedule BA Real Estate (gross of encumbrances)

LR007 Real Estate Column (3) Line (23)

(24)

Other Long-Term Assets

LR008 Other Long-Term Assets Column (4) Line (42)

(25)

Schedule BA Mortgages

LR009 Schedule BA Mortgages Column (6) Line (11)

(26)

Concentration Factor

LR010 Asset Concentration Factor Column (6) Line (40) Grand Total Page

(27)

Miscellaneous

LR011 Miscellaneous Assets Column (2) Line (15)

(28)

Replication Transactions and Manditorily Convertible Securities

LR012 Replication (Synthetic Asset) Transactions and Mandatorily Convertible Securities Column (6) Line (9999999)

(29)

Reinsurance

LR013 Reinsurance Column (4) Line (17)

L(30.1)

Total (C-1) - pre tax-UNAFFLIATED COMMON STOCK

LR005 COL(4) Line (17)+LR008Line(39)(e)+LR010aCol(6)Line(16)

L(30.2)

C-1 Tax Effect

LR026A Column (3) Line (103)

L(30.3)

Net (C-1) - post tax-unaffliated common stock

Line (30.1) - Line (30.2)

Total (C-1) - pre tax-nonUNAFFLIATED COMMON STOCK Assets

Sum of Lines (9) thru (29) less Line(30.1)

L(30.4)

Denotes items that must be manually entered on the filing software. CALCULATION OF AUTHORIZED CONTROL LEVEL RISK-BASED CAPITAL (CONTINUED) L(30.5)

C-1 Tax Effect

LR026A Column (3) Line (104)

L(30.6)

Net (C-1) - post tax-nonunaffliated common stock assets

Line (30.4) - Line (30.5)

(1) RBC Source

Insurance Risk (C-2) (31)

Individual and Industrial Life Insurance

(32)

Group and Credit Life Insurance and FEGI/SGLI

LR020 Life Insurance Column (2) Lines (19) and (20)

(33)

Total Health Insurance

LR019 Health Claim Reserves Column (2) Line (16)

(34)

Premium Stabilization Reserve Credit

LR021 Premium Stabilization Reserves Column (2) Line (10)

Total (C-2) - pre tax

Sum of Lines (31) through (34)

L(35.1)

Requirement


L(35.2)

(C-2) Tax Effect

LR026A Column (3) Line (109)

L(35.3)

Net (C-2) - post tax

Line (35.1) - Line (35.2)

Interest Rate Risk (C-3a) (36.1)

Total Interest Rate Risk Pre-Tax

LR022 Interest Rate Risk Column (3) Line (34)

(36.2)

C-3 Tax Effect

LR026A Column (3) Line (110)

(36.3)

Net (C-3) - Post-Tax

Line (36.1) - Line (36.2)

Health Credit Risk (C-3b) (37.1)

Total Health Credit Risk

LR023 Health Credit Risk Column (2) Line (7)

(37.2)

Tax Effect

LR026A Column (3) Line (111)

(37.3)

Net Health Credit Risk - Post-Tax

Line (37.1) - Line (37.2)

Business Risk (C-4) (38)

Premium Component

LR024 Business Risk Column (2) Lines (11) + (22) + (33)

(39)

Liability Component

(40.1)

Subtotal Business Risk (C-4a) Pre-Tax

LR024 Business Risk Column (2) Line (36) Lines (38) + (39)

(40.2)

C-4a Tax Effect

LR026A Column (3) Line (112)

(40.3)

Net (C-4a) - Post-Tax

Line (40.1) - Line (40.2)

(41.1)

Health Administrative Expense Component of Business Risk (C-4b)

LR024 Business Risk Column (2) Line (54)

(41.2)

Tax Effect

LR026A Column (3) Line (109)

(41.3)

Net Health Administrative Expense Component (C-4b) - Post-Tax

Line (41.1) - Line (41.2)

Total Risk-Based Capital After Covariance - post tax (42)

C-0 + C-4a + Square Root of [[(C-1)o + C-3a)]² +(C-1)² cs+ (C-2)² + (C-3b)² + (C-4b)² REPORT AMOUNT ON PARENT COMPANY'S RISK-BASED CAPITAL IF APPLICABLE. NOTE: USE POST-TAX RESULTS FOR EACH C-COMPONENT Authorized Control Level Risk-Based Capital (After Covariance Adjustment)


(43)

Total Risk-Based Capital After Covariance Times Fifty Percent

Line (42) x 0.50


CALCULATION FOR TAX FOR LIFE RBC ASSET RISKS

BONDS

(1)

(2)

(3)

RBC Amount

Tax Factor

RBC Tax

x

=

Long-term Bonds – Class 1

LR002 Col(2) Line (2)

0.2625

(2)

Long-term Bonds – Class 2

LR002 Col(2) Line (3)

0.2625

(3)

Long-term Bonds – Class 3

LR002 Col(2) Line (4)

0.2625

(4)

Long-term Bonds – Class 4

LR002 Col(2) Line (5)

0.2625

(5)

Long-term Bonds – Class 5

LR002 Col(2) Line (6)

0.35

(6)

Long-term Bonds – Class 6

LR002 Col(2) Line (7)

0.2625

(7)

Short-term Bonds – Class 1

LR002 Col(2) Line (10)

0.2625

(8)

Short-term Bonds – Class 2

LR002 Col(2) Line (11)

0.2625

(9)

Short-term Bonds – Class 3

LR002 Col(2) Line (12)

0.2625

(10)

Short-term Bonds – Class 4

LR002 Col (2) Line (13)

0.2625

(11)

Short-term Bonds – Class 5

LR002 Col (2) Line (14)

0.35

(12)

Short-term Bonds – Class 6

LR002 Col (2) Line (15)

0.35

(13)

Reinsurance Reductions

LR002 Col (2) Line (18)

0.35

(14)

Reinsurance Increases

LR002 Col (2) Line (19)

0.2625

(15)

Non-Exempt Class 1 Govt Agcy

LR002 Col (2) Line (21)

0.2625

(16)

Bonds Size Factor

LR002 Col (2) Line (25)

MORTGAGES IN GOOD STANDING (17)

Mortgages Farm

LR004 Col (6) Line (1)

0.2625

(18)

Residential Mortgages-insured

LR004 Col (6) Line (2)

0.2625

(19)

Residential Mortgages-other

LR004.Col (6).Line.(3)

0.2625

< >


(20)

Comm Mortgages-Insured

LR004.Col.(6).Line.(4)

0.2625

(21)

Comm Mortgages-other

LR004.Col (6) Line (5)

0.2625

(22)

Restructured Mortgages

LR004 Col (6) Line (6)

0.2625

(23)

Mortgages-Farm

LR004 Col (6) Line (7)

0.2625

(24)

Residential Mortgage-insured

LR004 Col (6) Line (8)

0.2625

(25)

Residential other

LR004 Col (6) Line (9)

0.2625

(26)

Commercial-insured

LR004 Col (6) Line (10)

0.2625

(27)

Commercial-other

LR004 Col (6) Line (11)

0.2625

LR004 Col (6) Line (12)

0.2625

90 DAYS OVERDUE

IN PROCESS FORECLOSURE (28)

Farm

(29)

Residential-insured

LR004 Col (6) Line (13)

0.2625

(30)

Residential-other

LR004 Col (6) Line (14)

0.2625

(31)

Commercial Mort.-insured

LR004 Col (6) Line (15)

0.2625

(32)

Commercial Mort-other

LR004 Col (6) Line (16)

0.2625

(33)

Due&Unpaid taxes Mortgages

LR004 Col (6) Line (17)

(34)

Due&Unpaid taxes-Foreclosures

LR004 Col (6) Line (18)

(35)

Reduction-reinsurance

LR004 Col (6) Line (20)

(36)

Increase-reinsurance

LR004 Col (6) Line (21)

0.2625 LESS

0.35 0.35

PREFERRED STOCK (37)

Unaff. Preferred Stock-Class 1

LR005 Col (4) Line (1)

0.2625

(38)

Unaff, Preferred Stock-Class 2

LR005 Col (4) Line (2)

0.2625

(39)

Unaff, Preferred Stock-Class 3

LR005 Col (4) Line (3)

0.2625

(40)

Unaff. Preferred Stock-Class 4

LR005 Col (4) Line (4)

0.2625

(41)

Unaff. Preferred Stock-Class 5

LR005 Col (4) Line (5)

0.2625

(42)

Unaff. Preferred Stock-Class 6

LR005 Col (4) Line (6)

0.35

< >


COMMON STOCK (43)

Unaff. Common Stock

LR005 Col (4) Line (13)

0.35

(44)

Stock-Reduction reinsurance

LR005 Col (4) Line (15)

0.35

(45)

Stock Increase reinsurance

LR005 Col (4) Line (16)

0.35

< >

SEPARATE ACCOUNTS (46)

Sep Acct- Guaranteed Index

LR006 Col (2) Line (1)

0.2625

(47)

Sep Acct Nonindex-Book reserv

LR006 Col (2) Line (2)

0.2625

(48)

Sep Acct Nonindex-Market resv

LR006 Col (2) Line (3)

0.2625

(49)

Sep Acct-Reduce reinsurance

LR006 Col (2) Line (5)

0.35

(50)

Sep Acct-Increase reinsurance

LR006 Col (2) Line (6)

0.35

(51)

Synthetic GICs

LR006 Col (2) Line (8)

0.2625

(52)

Sep Acct Surplus

LR006 Col (2) Line (13)

0.2625

< >

REAL ESTATE (53)

Company Occup Real Estate

LR007 Col (3) Line (4)

0.35

(54)

Foreclosed Real Estate

LR007 Col (3) Line (8)

0.35

(55)

Investment Real Estate

LR007 Col (3) Line (12)

0.35

(56)

R.E. Reduction reinsurance

LR007 Col (3) Line (14)

0.35

(57)

R.E. Increase reinsurance

LR007 Col (3) Line 15)

0.35

(58)

Sch BA Real Estate

LR007 Col.(3) Line (23)

0.35

(59)

Sch BA Bond Class 1

LR008 Col (4) Line (2)

0.2625

(60)

Sch BA Bond Class 2

LR008 Col (4) Line (3)

0.2625

(61)

Sch BA Bond Class 3

LR008 Col (4) Line (4)

0.2625

(62)

Sch BA Bond Class 4

LR008 Col (4) Line (5)

0.2625

(63)

Sch BA Bond Class 5

LR008 Col (4) Line (6)

0.2625

(64)

Sch BA Bond Class 6

LR008 Col (4) Line (7)

0.35

SCHEDULE BA

< >


(65)

Reduce reinsurance

LR008 Col (4) Line (9)

(66)

Increase reinsurance

LR008 Col (4) Line 10)

LESS

0.35

(67)

BA Preferred Stock class 1

LR008 Col (4) Line (12.3)

0.2625

(68)

BA Pref. Stock Class 2

LR008 Col (4) Line (13)

0.2625

(69)

BA Pref. Stock Class 3

LR008 Col (4) Line (14)

0.2625

(70)

BA Pref. Stock Class 4

LR008 Col (4) Line (15)

0.2625

(71)

BA Pref. Stock Class 5

LR008 Col (4) Line (16)

0.2625

(72)

BA Pref. Stock Class

LR008 Col (4) Line (17)

0.35

(73)

Reduce reinsurance

LR008 Col (4) Line (19)

(74)

Increase reinsurance

LR008 Col (4) Line (20)

0.35

(75)

Rated Surplus Notes

LR008 Col (4) Line (31)

0.2625

(76)

Rated Capital Notes

LR008 Col (4) Line (38)

0.2625

(77)

BA Common Stock Unaffliated

LR008 Col (4) Line (39) (e)

(78)

BA Common Stock Affliated

LR008 Col(4) Line (39) (f)

(79)

BA Loans

LR008 Col (4) Line (40)

(80)

Other BA Assets

LR008 Col (4) Line (41.3)

(81)

BA Mortgages-insured/guar

LR009 Col (6) Line (1)

0.2625

(82)

BA Mortgages-all other

LR009 Col (6) Line (2)

0.2625

LESS

0.35

< >

0.35 0.35 0.2625 0.35

(83)

BA restructured mortgages

LR009 Col (6) Line (3)

0.2625

(84)

BA mortgages 90 days overdue

LR009 Col (6) Line (4)+Line (5)

0.2625

(85)

BA Mort. Foreclosed-insured

LR009 Col (6) Line (6)

0.2625

(86)

BA Mort. Foreclosed-all other

LR009 Col (6) Line (7)

0.2625

(87)

Reduce reinsurance

LR009 Col (6) Line (9)

(88)

Increase reinsurance

LR009 Col (6) Line (10)

0.35

Asset Concentration Factor

LR010 Col (6) Line (40)

0.2625

(90)

Common Stock Concentration F.

LR010a Col (6) Line (16)

0.2625

(91)

Miscellaneous Assets

LR011 Col (2) Line (6)

0.2625

(92)

Derivatives

LR011 Col (2) Line (7)

0.2625

LESS

0.35

MISCELLANEOUS (89)

< >

0.35

< >


(93)

Derivatives class 1

LR011 Col (2) Line (8)

0.2625

(94)

Derivatives Class 2

LR011 Col (2) Line (9)

0.2625

(95)

Derivatives class 3

LR011 Col (2) Line (10)

0.2625

(96)

Derivatives class 4

LR011 Col (2) Line (13)

0.2625

(97)

Derivatives class 5

LR011 Col (2) Line (14)

0.2625

(98)

Derivatives class 6

LR011 Col (2) Line (15)

0.35

(99)

Replications

LR012 Col (7) Line (44) or Lines (1) through (35)

0.2625

(100)

Off Balance Sheet Items

LR014 Col (2) Line (23)

0.2625

(101)

Reinsurance credits

LR025 Col (1) Line (29)

0.35

(102)

SUBTOTAL FOR ASSETS TAX

Total Lines (1) to (101)

(103)

SUBTOTAL FOR COMMON STOCK TAX

LINES (43)+(44)+(45)+(77)+(90)

(104)

SUBTOTAL FOR ASSETS TAX OTHER THAN COMMON STOCK

Line (102)--(103)

LIFE INSURANCE RISKS (105)

Life insurance C2 Risk

LR025 Col (1) Line (31)

0.35

(106)

Group Insurance C2 Risks

LR025 Col (1) Line (32)

0.35

(107)

Health Insurance C2 Risks

LR025 Col (1) Line (33)

0

(108)

Prem Stabilization Credit

LR025 Col (1) Line (34)

0.35

(109)

TOTAL C2 RISK

Lines (101)+(102)+(103)+(104)

(110)

Interest Rate Risk

LR025 Col (1) Line (36)

0.35

(111)

Health Credit Risk

LR025 Col (1) Line (37)

0

(112)

Business Risk

LR025 Col (1) Line (40)

0.35

(113)

Health Admin Expense Comp.

LR025 Col (1) Line (41)

0

TOTAL TAX Lines (102)+(109)+(110)+(111)+(112)+(113)

< >


< > subtract

LR026A


Company Name

Confidential when Completed

NAIC Company Code

Affix Bar Code Here

COMPANY INFORMATION PAGE (JURAT) Life Risk-Based Capital For the Year Ending December 31, 2000

(A) Company Name (B) NAIC Group Code

(C) NAIC Company Code

(D) Employer's ID Number

(G) Middle

(H)

(E) Organized under the Laws of the State of Contact Person for Life Risk-Based Capital: (F) First Name

Last Name

(I) Mail Address of Contact Person (Street and Number of P.O. Box) (J) City

(K) State

(M) Phone Number of RBC Contact Person

(L) Zip

Extension

(N) Date Prepared (O) Preparer (if different than Contact) (P) Is this filing an Original, Amended or Refiling? (P1) If Amended, Amendment Number: (Q) Was a vendor link file used to prepare this filing? (Yes or No) Officers Name: Officers Title: Each says that they are the above described officers of the said insurer, and that this risk-based capital report is a true and fair representation of the companyâ&#x20AC;&#x2122;s affairs and has been completed in accordance with the NAIC instructions according to the best of their information, knowledge and belief, respectively.

(Signature)

(Signature)

(Signature)

Denotes items that must be manually entered on the filing software.

Š 2000 National Association of Insurance Commissioners

LR001

6/30/2000


Company Name

Confidential when Completed

NAIC Company Code

BONDS

(1) (2) (3) (4) (5) (6) (7) (8)

(9) (10) (11) (12) (13) (14) (15) (16) (17) (18) (19) (20) (21) (22) (23) (24) (25)

(1) SVO Bond Rating Category Annual Statement Source Statement Value Long Term Bonds Exempt Obligations AVR Default Component Column 1 Line 1 Asset Class 1 AVR Default Component Column 1 Line 2 Asset Class 2 AVR Default Component Column 1 Line 3 Asset Class 3 AVR Default Component Column 1 Line 4 Asset Class 4 AVR Default Component Column 1 Line 5 Asset Class 5 AVR Default Component Column 1 Line 6 Asset Class 6 AVR Default Component Column 1 Line 7 Total Long-Term Bonds Sum of Lines (1) through (7) (Column (1) should equal Page 2 Column 4 Line 1) Short Term Bonds Exempt Obligations AVR Default Component Column 1 Line 18 Asset Class 1 AVR Default Component Column 1 Line 19 Asset Class 2 AVR Default Component Column 1 Line 20 Asset Class 3 AVR Default Component Column 1 Line 21 Asset Class 4 AVR Default Component Column 1 Line 22 Asset Class 5 AVR Default Component Column 1 Line 23 Asset Class 6 AVR Default Component Column 1 Line 24 Total Short-Term Bonds Sum of Lines (9) through (15) (Column (1) shold equal Schedule DA Part 1 Column 13 Lines 6099999+7799999+7899999) Total Long-Term and Short-Term Bonds Line (8) + (16) (pre-MODCO/Funds Withheld) Reduction in RBC for MODCO/Funds Withheld Reinsurance Ceded Agreements Company Records Increase in RBC for MODCO/Funds Withheld Reinsurance Assumed Agreements Company Records Total Long-Term and Short-Term Bonds Lines (17) - (18) + (19) (including MODCO/FundsWithheld adjustments.) Non-exempt Asset Class 1 U.S. Schedule D Part 1 Class 1 Bonds and Schedule DA Part 1 Government Agency Bonds Class 1 Bonds, in part† Bonds Subject to Size Factor Line (20) - Line (1) - Line (9) - Line (21) Number of Issuers Company Records Size Factor for Bonds Bonds Subject to Size Factor after the Size Line (22) x Line (24) Factor is Applied

(26) Total Bonds †

(2) RBC Requirement

Factor X X X X X X X

0.000 0.004 0.013 0.046 0.100 0.230 0.300

= = = = = = =

X X X X X X X

0.000 0.004 0.013 0.046 0.100 0.230 0.300

= = = = = = =

X 0.004

=

Line (21) + Line (25)

Only investments in asset Class 1 U.S. Government agency bonds previously reported in Lines (2) and (10), net of those included on Line (18), plus the portion of Line (19) attributable to ceding companies' Lines (2) and (10) should be included on Line (21). No other class 1 bonds should be included on this line. Exempt U.S. Government bonds shown on Lines (1) and (9) should not be included on Line (21). Refer to the bond section of the risk-based capital instructions for more clarification. Denotes items that must be manually entered on the filing software.

© 2000 National Association of Insurance Commissioners

LR002

6/30/2000


Company Name

Confidential when Completed

NAIC Company Code

MORTGAGE EXPERIENCE ADJUSTMENT (1) (1) Does the company have 5 plus years of mortgage experience? Enter "Yes or "No".

(2) (3) (4) (5) (6) (7) (8) (9) (10)

Quarter and Year September 1998 December 1998 March 1999 June 1999 September 1999 December 1999 March 2000 June 2000 September 2000

(2) Farm and Commercial Mortgages With Restructured Terms

(3) Farm and Commercial Mortgages 90 Days Overdue

(4) (5) Farm and Commercial Year-to-Date Farm and Mortgages Commercial Mortgages In Process of Foreclosure Transferred to Real Estate

(6) Farm and Commercial Mortgages In Good Standing

(7)

Ratio† xxxxxxxx ‡

(11) Company Normalized Loss Ratio (Average of Column (6) Lines (3) through (10)) (12) Industry Normalized Loss Ratio (Provided by the NAIC) § (13) Mortgage Experience Adjustment Factor for Mortgages in Good Standing Company Normalized Loss Ratio Line (11) divided by Industry Composite Ratio Line (12) (not more than 350 percent nor less than 50 percent)

§

Column (7) calculation for quarterly amounts: [0.010 multiplied by the average of [Column (2) current quarter plus Column (2) previous quarter] plus 0.020 multiplied by the average of [Column (3) current quarter plus Column (3) previous quarter] plus 0.025 multiplied by the average of [Column (4) current quarter plus Column (4) previous quarter] plus 0.120 multiplied by [Column (5) current quarter less Column (5) previous quarter]] divided by [the average of [Columns (2), (3), (4) and (6) current quarter plus Columns (2), (3), (4) and (6) previous quarter] plus one-half of [Column (5) current quarter less Column (5) previous quarter]] Column (7) calculation for first quarterly amounts: [0.010 multiplied by the average of [Column (2) current quarter plus Column (2) previous quarter] plus 0.020 multiplied by the average of [Column (3) current quarter plus Column (3) previous quarter] plus 0.025 multiplied by the average of [Column (4) current quarter plus Column (4) previous quarter] plus 0.120 multiplied by Column (5) current quarter] divided by [the average of [Columns (2), (3), (4) and (6) current quarter plus Columns (2), (3), (4) and (6) previous quarter] plus one-half of Column (5) current quarter] The 2000 Industry Average Delinquency Rate will be available December 2000. Denotes items that must be manually entered on the filing software.

© 2000 National Association of Insurance Commissioners

LR003

6/30/2000


Company Name

Confidential when Completed

NAIC Company Code

MORTGAGES (1)

Annual Statement Source (1) (2) (3) (4) (5) (6) (7) (8) (9) (10) (11) (12) (13) (14) (15) (16) (17) (18)

In Good Standing Farm Mortgages Residential Mortgages-Insured or Guaranteed Residential Mortgages-All Other Commercial Mortgages-Insured or Guaranteed Commercial Mortgages-All Other Restructured Mortgages 90 Days Overdue, Not in Process of Foreclosure Farm Mortgages Residential Mortgages-Insured or Guaranteed Residential Mortgages-All Other Commercial Mortgages-Insured or Guaranteed Commercial Mortgages-All Other In Process of Foreclosure Farm Mortgages Residential Mortgages-Insured or Guaranteed Residential Mortgages-All Other Commercial Mortgages-Insured or Guaranteed Commercial Mortgages-All Other Due and Unpaid Taxes Due and Unpaid Taxes on Mortgages Overdue, Not in Process of Foreclosure Due and Unpaid Taxes on Foreclosed Mortgages

Statement Value

(2) Involuntary Reserve Adjustment†

(3) Adjusted Statement Value

(4)

(5)

(6)

Cumulative Writedowns‡

Average Factor

RBC Requirement

XXX XXX XXX XXX XXX XXX

X § = X 0.0014 = X 0.0068 = X ,0014 = X § = X * =

AVR Default Component Column 1 Line 35 AVR Default Component Column 1 Line 36 AVR Default Component Column 1 Line 37 AVR Default Component Column 1 Line 38 AVR Default Component Column 1 Line 39 AVR Default Component Column 1 Line 40 AVR Default Component Column 1 Line 41 AVR Default Component Column 1 Line 42 AVR Default Component Column 1 Line 43 AVR Default Component Column 1 Line 44 AVR Default Component Column 1 Line 45

X X X X X

£ £ £ £ £

= = = = =

AVR Default Component Column 1 Line 46 AVR Default Component Column 1 Line 47 AVR Default Component Column 1 Line 48 AVR Default Component Column 1 Line 49 AVR Default Component Column 1 Line 50

X X X X X

£ £ £ £ £

= = = = =

Schedule B Part 1 Footnote #3 1st amount Schedule B Part 1 Footnote #4 1st amount

X

1.000 =

X

1.000 =

(19) Total Mortgages (including due and unpaid taxes) Sum of Lines (1) through (18) (Column (1) should equal Page 2 Column 4 Lines 3.1 + 3.2 + Schedule B Part 1 Footnote #3 1st amount + Schedule B Part 1 Footnote #4 1st amount). (20) Reduction in RBC for MODCO/Funds Withheld Reinsurance Ceded Agreements Company Records (21) Increase in RBC for MODCO/Funds Withheld Reinsurance Assumed Agreements Company Records (22) Total Mortgages (including MODCO/Funds Withheld.) Lines (19) - (20) + (21)

† ‡ § * £

Involuntary reserves are reserves that are held as an offset to a particular asset that is clearly a troubled asset and are included on Page 3 Line 25 of the Annual Statement. Cumulative writedowns include the total amount of writedowns, non-admissions, and involuntary reserves that have been taken or established with respect to a particular mortgage. For Lines (1) and (5), Column (5) is equal to 0.0260 multiplied times the experience adjustment factor on LR003 Mortgage Experience Adjustment Factor Line (13). For Line (6), Column (5) is the greater of 0.0860 or 0.00.0260 multiplied times experience adjustment factor For Lines (7) through (16), Column (5) is calculated as Column (6) divided by Column (3). Denotes items that must be manually entered on the filing software.

© 2000 National Association of Insurance Commissioners

LR004

6/30/2000


Company Name

Confidential when Completed

NAIC Company Code

UNAFFILIATED PREFERRED AND COMMON STOCK (1)

Annual Statement Source Unaffiliated Preferred Stock Asset Class 1 Asset Class 2 Asset Class 3 Asset Class 4 Asset Class 5 Asset Class 6

(1) (2) (3) (4) (5) (6)

Statement Value

AVR Default Component Column 1 Line 10 AVR Default Component Column 1 Line 11 AVR Default Component Column 1 Line 12 AVR Default Component Column 1 Line 13 AVR Default Component Column 1 Line 14 AVR Default Component Column 1 Line 15

(2) Less Affiliated Preferred Stock Without AVR

(3)

(4)

RBC Subtotal

RBC Requirement

Factor X X X X X X

0.011 0.030 0.072 0.150 0.250 0.300

= = = = = =

(7) Total Unaffiliated Preferred Stock Sum of Lines (1) through (6) (Column (1) should equal Page 2 Column 4 Line 2.1 less Asset Valuation Reserve Default Component Column 1 Line 16.) (Column (2) should equal Schedule D Summary Column 5 Line 39 less Asset Valuation Reserve Default Component Column 1 Line 16.) Unaffiliated Common Stock Total Common Stock Less Affiliated Common Stock Less Money Market Funds Less Federal Home Loan Bank Common Stock (12) Net Other Unaffiliated Common Stock (8) (9) (10) (11)

Schedule D Summary Column 2 Line 54 Schedule D Summary Column 2 Line 53 Included in Schedule D Part 2 Section 2 Included in Schedule D Part 2 Section 2

X 0.004 = X 0.027 =

Lines (8) - (9) - (10) - (11)

X 0.300 =

(13) Total Unaffiliated Common Stock Lines (10) + (11) + (12) (Column 1 should equal Page 2 Column 4 Line 2.2 less Schedule D Summary by Country Column 2 Line 53) (14) Total Unaffiliated Preferred and Common Stock (pre-MODCO/Funds Withheld) (15) Reduction in RBC for MODCO/Funds Withheld Reinsurance Ceded Agreements (16) Increase in RBC for MODCO/Funds Withheld Reinsurance Assumed Agreements

Line (7) + Line (13)

(17) Total Unaffiliated Preferred and Common Stock (including MODCO/Funds Withheld.)

Lines (14) - (15) + (16)

Company Records Company Records

Denotes items that must be manually entered on the filing software.

Š 2000 National Association of Insurance Commissioners

LR005

6/30/2000


Company Name

Confidential when Completed

NAIC Company Code

SEPARATE ACCOUNTS Annual Statement Source Separate Accounts with Guarantees (1) Guaranteed Indexed (2) Non-Indexed, Reserved at Book Value (3) Non-Indexed, Reserved at Market Value (4) Total Assets in Separate Accounts with Guarantees† (pre-MODCO/Funds Withheld) (5) Reduction in RBC for MODCO/Funds Withheld Reinsurance Ceded Agreements (6) Increase in RBC for MODCO/Funds Withheld Reinsurance Assumed Agreements (7) Total Assets in Separate Accounts with Guarantees (including MODCO/Funds Withheld.) Synthetic GIC's (8) Synthetic GIC's C-1 Requirement Surplus in Non-Guaranteed Separate Accounts Assets in Separate Accounts Less Liabilities in Separate Accounts Expense Allowance Transfers - All Other Expense Allowance Transfers - Surrender Charge Based on Fund Contribution and the Fund Balance Exceeds the Sum of the Premiums Less Withdrawals (13) Total Surplus in Non-Guaranteed Separate Accounts† (9) (10) (11) (12)

(14) Total Separate Accounts Assets (Column (1) should equal Page 2 Column 4 Line 24)

† ‡

(1) Statement Value

Page 2 Column 4 Line 24 in part Company records Company records

Factor or Calc X

(2) RBC Requirement

0.004 = RBC x 1.000 RBC x 1.000 (less "haircut")

Lines (1) + (2) + (3)

Company Records Company Records Lines (4) - (5) + (6)

Company records

RBC x 1.000 (less "haircut")

Page 2 Column 4 Line 24 in part Page 3 Column 1 Line 27 in part Page 3 Column 1 Line 13A‡ in part Page 3 Column 1 Line 13A‡ in part

X X X X

0.110 0.110 0.110 0.024

= = = =

Lines (9) - (10) + (11) + (12) Lines (4) + (9)

The amount reported in Column (2) should not be less than zero. The statement value of expense allowance transfers for Lines (11) and (12) should be entered as a positive value. Denotes items that must be manually entered on the filing software.

© 2000 National Association of Insurance Commissioners

LR006

6/30/2000


Company Name

Confidential when Completed

NAIC Company Code

REAL ESTATE (1) Annual Statement Source

(2) Average Factor

Statement Value

(3) RBC Requirement ‡

(1) (2) (3) (4)

Real Estate Company Occupied Real Estate Company Occupied Involuntary Reserves Company Occupied Encumbrances Total Company Occupied Real Estate

Page 2 Column 4 Line 4.1 Page 3 Column 1 Line 25, in part Page 2 Inside Amount Line 4.1 Line (1) - (2) + (3)

X

=

(5) (6) (7) (8)

Foreclosed Real Estate Foreclosed Involuntary Reserves Foreclosed Encumbrances Total Foreclosed Real Estate

Page 2 Column 4 Line 4.2 Page 3 Column 1 Line 25, in part Page 2 Inside Amount Line 4.2 Line (5) - (6) + (7)

X

=

(9) (10) (11) (12)

Investment Real Estate Investment Involuntary Reserves Investment Encumbrances Total Investment Real Estate

Page 2 Column 4 Line 4.3 Page 3 Column 1 Line 25, in part Page 2 Inside Amount Line 4.3 Line (9) - (10) + (11)

X

=

X

=

(13) Total Real Estate (pre-MODCO/Funds Withheld) (14) Reduction in RBC for MODCO/Funds Withheld Reinsurance Ceded Agreements (15) Increase in RBC for MODCO/Funds Withheld Reinsurance Assumed Agreements (16) Total Real Estate (including MODCO/Funds Withheld.) Schedule BA Real Estate (17) Schedule BA Real Estate (18) Schedule BA Real Estate Involuntary Reserves (19) Schedule BA Real Estate Encumbrances (20) Total Schedule BA Real Estate (pre-MODCO/Funds Withheld) (21) Reduction in RBC for MODCO/Funds Withheld Reinsurance Ceded Agreements (22) Increase in RBC for MODCO/Funds Withheld Reinsurance Assumed Agreements (23) Total Schedule BA Real Estate (including MODCO/Funds Withheld.) † ‡

Lines (4) + (8) + (12)

Company Records Company Records Lines (13) - (14) + (15)

Schedule BA Column 10 Line 0999999 Page 3 Column 1 Line 25, in part Schedule BA Column 7 Line 0999999 Line (17) - (18) + (19)

Company Records Company Records Lines (20) - (21) + (22)

Column (2) is calculated as Column (3) divided by Column (1). The RBC requirement is calculated for each individual property and then summarized on this page. Refer to the worksheet included in the Real Estate portion of the instructions. Denotes items that must be manually entered on the filing software.

© 2000 National Association of Insurance Commissioners

LR007

6/30/2000


Company Name

Confidential when Completed

NAIC Company Code

OTHER LONG-TERM ASSETS (1) Statement Value

Annual Statement Source (1) (2) (3) (4) (5) (6) (7) (8)

Schedule BA - Fixed Income - Bonds Exempt Obligations Asset Class 1 Asset Class 2 Asset Class 3 Asset Class 4 Asset Class 5 Asset Class 6 Total Schedule BA Bonds

(pre-MODCO/Funds Withheld) Reduction in RBC for MODCO/Funds Withheld Reinsurance Ceded Agreements (10) Increase in RBC for MODCO/Funds Withheld Reinsurance Assumed Agreements (11) Total Schedule BA Bonds (including MODCO/Funds Withheld.)

(2)

(3)

Unrated Items †

RBC Subtotal ‡

AVR Equity Component Column 1 Line 22 AVR Equity Component Column 1 Line 23 AVR Equity Component Column 1 Line 24 AVR Equity Component Column 1 Line 25 AVR Equity Component Column 1 Line 26 AVR Equity Component Column 1 Line 27 AVR Equity Component Column 1 Line 28 Sum of Lines (1) through (7)

(4) RBC Requirement

Factor X X X X X X X

0.000 0.004 0.013 0.046 0.100 0.230 0.300

= = = = = = =

X X X X X X

0.011 0.030 0.072 0.150 0.250 0.300

= = = = = =

(9)

Schedule BA - Fixed Income - Preferred Stock (12.1) Asset Class 1 (12.2) Less Rated Class 1 Surplus Notes and Capital Notes (12.3) Net Asset Class 1 (13) Asset Class 2 (14) Asset Class 3 (15) Asset Class 4 (16) Asset Class 5 (17) Asset Class 6 (18) Total Schedule BA Preferred Stock (pre-MODCO/Funds Withheld) (19) Reduction in RBC for MODCO/Funds Withheld Reinsurance Ceded Agreements (20) Increase in RBC for MODCO/Funds Withheld Reinsurance Assumed Agreements (21) Total Schedule BA Preferred Stock (including MODCO/Funds Withheld.)

† ‡

Company Records Company Records Lines (8) - (9) + (10)

AVR Equity Component Column 1 Line 30 Column (1) Line (22) + Column (1) Line (32) Line (12.1) - (12.2) AVR Equity Component Column 1 Line 31 AVR Equity Component Column 1 Line 32 AVR Equity Component Column 1 Line 33 AVR Equity Component Column 1 Line 34 AVR Equity Component Column 1 Line 35 Sum of Lines (12.3) through (17)

Company Records Company Records Lines (18) - (19) + (20)

Fixed income instruments and surplus notes rated by the NAIC Securities Valuation Office (SVO) should be reported in Column (3). Column (2) is calculated as Column (1) less Column (3) for Lines (1) through (17). Column (2) equals Column (3) - Column (1) for Line (41.3). Denotes items that must be manually entered on the filing software.

© 2000 National Association of Insurance Commissioners

LR008

6/30/2000


Company Name

Confidential when Completed

NAIC Company Code

OTHER LONG-TERM ASSETS (CONTINUED) (1) Statement Value

Annual Statement Source

(22) (23) (24) (25) (26) (27) (28)

Rated Surplus Notes Rated Class 1 Surplus Notes Rated Class 2 Surplus Notes Rated Class 3 Surplus Notes Rated Class 4 Surplus Notes Rated Class 5 Surplus Notes Rated Class 6 Surplus Notes Total Rated Surplus Notes

(pre-MODCO/Funds Withheld) (29) Reduction in RBC for MODCO/Funds Withheld Reinsurance Ceded Agreements (30) Increase in RBC for MODCO/Funds Withheld Reinsurance Assumed Agreements (31) Total Rated Surplus Notes (including MODCO/Funds Withheld.)

(32) (33) (34) (35) (36) (37) (38)

Rated Capital Notes Rated Class 1 Capital Notes Rated Class 2 Capital Notes Rated Class 3 Capital Notes Rated Class 4 Capital Notes Rated Class 5 Capital Notes Rated Class 6 Capital Notes Total Rated Capital Notes

Schedule BA - All Other Schedule BA Common Stock Schedule BA Collateral Loans Other Schedule BA Assets Less Class 2 thru 6 Rated Surplus Notes and Capital Notes (41.3) Net Other Schedule BA Assets (39) (40) (41.1) (41.2)

(42) Total Schedule BA Assets

† ‡

(2)

(3)

Unrated Items †

RBC Subtotal ‡

Schedule BA Part 1 Column 10 Line 1199999, in part Schedule BA Part 1 Column 10 Line 1199999, in part Schedule BA Part 1 Column 10 Line 1199999, in part Schedule BA Part 1 Column 10 Line 1199999, in part Schedule BA Part 1 Column 10 Line 1199999, in part Schedule BA Part 1 Column 10 Line 1199999, in part Sum of Lines (22) through (27)

(4) RBC Requirement

Factor

X X X X X X

0.011 0.030 0.072 0.150 0.250 0.300

= = = = = =

Schedule BA Part 1 Column 10 Line 1399999, in part Schedule BA Part 1 Column 10 Line 1399999, in part Schedule BA Part 1 Column 10 Line 1399999, in part Schedule BA Part 1 Column 10 Line 1399999, in part Schedule BA Part 1 Column 10 Line 1399999, in part Schedule BA Part 1 Column 10 Line 1399999, in part Sum of Lines (32) through (37)

X X X X X X

0.011 0.030 0.072 0.150 0.250 0.300

= = = = = =

AVR Equity Component Column 1 Line 60 Schedule BA Part 1 Column 10 Line 1299999 AVR Equity Component Column 1 Line 65 Column (1) Lines (23) through (27) + Column (1) Lines (33) through (37) Line (41.1) less (41.2)

X 0.300 = X 0.068 =

Company Records Company Records Lines (28) - (29) + (30)

X 0.300 =

Lines (11) + (21) + (31) + (38) + (39) + (40) + (41.3)

Fixed income instruments and surplus notes rated by the NAIC Securities Valuation Office (SVO) should be reported in Column (3). Column (2) is calculated as Column (1) less Column (3) for Lines (1) through (17). Column (2) equals Column (3) - Column (1) for Line (41.3). Denotes items that must be manually entered on the filing software.

© 2000 National Association of Insurance Commissioners

LR008

6/30/2000


Company Name

Confidential when Completed

NAIC Company Code

SCHEDULE BA MORTGAGES (1)

Annual Statement Value (1) Insured or Guaranteed in Good Standing (2) All Other in Good Standing (3) Restructured (4) Insured or Guaranteed 90 Days Overdue (5) All Other 90 Days Overdue (6) Insured or Guaranteed in Process of Foreclosure (7) All Other in Process of Foreclosure

Statement Value

(2) Involuntary Reserve Adjustment †

(3) Adjusted Statement Value

(4)

(5)

(6)

Cumulative Writedowns ‡

Average Factor

RBC Requirement

Schedule BA Part 1 Column 10 Line 0599999, in part

XXX

X

0.0010

=

Schedule BA Part 1 Column 10 Line 0599999, in part AVR Equity Component Column 1 Line 43 Schedule BA Part 1 Column 10 Line 0599999, in part

XXX XXX

X X X

§ * £

= = =

Schedule BA Part 1 Column 10 Line 0599999, in part Schedule BA Part 1 Column 10 Line 0599999, in part

X X

£ £

= =

Schedule BA Part 1 Column 10 Line 0599999, in part

X

£

=

(8) Total Schedule BA Mortgages Sum of Lines (1) through (7) (pre-MODCO/Funds Withheld) (9) Reduction in RBC for MODCO/Funds Withheld Reinsurance Ceded Agreements Company Records (10) Increase in RBC for MODCO/Funds Withheld Reinsurance Assumed Agreements Company Records (11) Total Schedule BA Mortgages (including MODCO/Funds Withheld.) Lines (8) - (9) + (10)

† ‡ § * £

Involuntary reserves are reserves that are held as an offset to a particular asset that is clearly a troubled asset and are included on Page 3 Line 25 of the Annual Statement. Cumulative writedowns include the total amount of writedowns, non-admissions, and involuntary reserves that have been taken or established with respect to a particular mortgage. For Line (2), Column (5) is equal to 0.0260 multiplied times the experience adjustment factor on LR003 Mortgage Experience Adjustment Factor Line (13). For Line (3), Column (5) is the greater of 0f 0.086 or 0.026 times [the experience adjustment factor on LR003 Mortgage Experience Adjustment Factor Line (13) 13]. For Lines (4) through (7), Column (5) is calculated as Column (6) divided by Column (3). Denotes items that must be manually entered on the filing software.

© 2000 National Association of Insurance Commissioners

LR009

6/30/2000


Company Name

Confidential when Completed

NAIC Company Code

ASSET CONCENTRATION FACTOR (1)

(1) (2) (3) (4) (5) (6) (7) (8) (9) (10) (11) (12) (13) (14) (15) (16) (17) (18) (19) (20) (21) (22) (23) (24) (25) (26) (27) (28)

† ‡

Asset Type Issuer Name: Bond Asset Class 2 Bond Asset Class 3 Bond Asset Class 4 Bond Asset Class 5 Bond Asset Class 1 † Unaffiliated Preferred Stock Class 2 Unaffiliated Preferred Stock Class 3 Unaffiliated Preferred Stock Class 4 Unaffiliated Preferred Stock Class 5 Collateral Loans Receivable for Securities Write-ins for Invested Assets Premium Notes Real Estate - Foreclosed Real Estate - Foreclosed Encumbrances Real Estate - Investments Real Estate - Investment Encumbrances Real Estate - Schedule BA Real Estate - Schedule BA Encumbrances Farm Mortgages in Good Standing Commercial Mortgages in Good Standing Commercial Mortgages in Good Standing w/Restructured Terms Farm Mortgages - 90 Days Overdue Farm Mortgages - 90 Days Overdue - Cumulative Writedowns Residential Mortgages - 90 Days Overdue Residential Mortgages - 90 Days Overdue - Cumulative Writedowns Commercial Mortgages - 90 Days Overdue Commercial Mortgages - 90 Days Overdue - Cumulative Writedowns

(2)

(3)

(4)

Statement Value

Factor

Additional RBC

X X X X X X X X X X X X X

0.0130 0.0460 0.1000 0.2300 0.0040 0.0030 0.0720 0.1500 0.2500 0.0680 0.0680 0.0680 0.0680

= = = = = = = = = = = = =

X

=

X

=

X X X X

‡ ‡ ‡ ‡

= = = =

X

=

X

=

X

=

(5) Adjustment/ Subsidiary RBC

(6) RBC Requirement

After the ten largest issuer exposures are chosen, any class 1 bonds from any of these issuers should be included. Refer to the instructions for the Asset Concentration Factor for details of this calculation. Denotes items that must be manually entered on the filing software.

© 2000 National Association of Insurance Commissioners

LR010

6/30/2000


Company Name

Confidential when Completed ASSET CONCENTRATION FACTOR (CONTINUED) (1)

Asset Type (29) (30) (31) (32) (33) (34) (35) (36) (37) (38) (39)

Farm Mortgages in Foreclosure Farm Mortgages in Foreclosure - Cumulative Writedowns Residential Mortgages in Foreclosure Residential Mortgages in Foreclosure - Cumulative Writedowns Commercial Mortgages in Foreclosure Commercial Mortgages in Foreclosure - Cumulative Writedowns Schedule BA Mortgages in Good Standing Schedule BA Mortgages 90 Days Overdue Schedule BA Mortgages 90 Days Overdue - Cumulative Writedowns Schedule BA Mortgages in Process of Foreclosure Schedule BA Mortgages Foreclosed - Cumulative Writedowns

(40)

Sum of Lines (1) through (39)

NAIC Company Code

(2)

(3)

(4)

Statement Value

Factor

Additional RBC

X

=

X

=

X X

‡ ‡

= =

X

=

X

=

(5) Adjustment/ Subsidiary RBC

(6) RBC Requirement

NOTE: Ten issuer sections and a grand total page will be available on the filing software.

Refer to the instructions for the Asset Concentration Factor for details of this calculation. Denotes items that must be manually entered on the filing software.

© 2000 National Association of Insurance Commissioners

LR010

6/30/2000


Company Name

Confidential when Completed

NAIC Company Code

MISCELLANEOUS ASSETS (1) Statement Value

Annual Statement Source Miscellaneous (1) Cash (2.1) (2.2) (2.3) (2.4) (2.5)

Short-Term Investments Less Short-Term Bonds Less Exempt Money Market Funds Less Class One Money Market Funds Net Short-Term Investments

(3) Premium Notes (4) Receivable for Securities (5.1) Aggregate Write-ins for Invested Assets (5.2) Less Derivative Instruments (5.3) Net Write-ins for Invested Assets

(2) RBC Requirement

Factor

Page 2 Column 4 Line 7 first inside amount

X 0.004 =

Page 2 Column 4 Line 7 second inside amount Schedule DA Part 1 Column 13 Line 6099999 Schedule DA Part 1 Column 13 Line 7799999 Schedule DA Part 1 Column 13 Line 7899999 Lines (2.1) - (2.2) - (2.3) - (2.4)

X 0.004 =

Page 2 Column 4 Line 6 Page 2 Column 4 Line 9 Page 2 Column 4 Line 10 Asset Valuation Reserve Default Component Column 1 Line 33 Line (5.1) - Line (5.2)

X 0.068 = X 0.068 =

X 0.068 =

(6) Total Miscellaneous Excluding Derivative Lines (1) + (2.5) + (3) + (4) + (5.3) Instruments

(7) (8) (9) (10) (11) (12) (13)

Derivative Instruments Exchange Traded Over the Counter Class 1 Over the Counter Class 2 Over the Counter Class 3 Over the Counter Class 4 Over the Counter Class 5 Over the Counter Class 6

Asset Valuation Reserve Default Component Column 1 Line 26 Asset Valuation Reserve Default Component Column 1 Line 27 Asset Valuation Reserve Default Component Column 1 Line 28 Asset Valuation Reserve Default Component Column 1 Line 29 Asset Valuation Reserve Default Component Column 1 Line 30 Asset Valuation Reserve Default Component Column 1 Line 31 Asset Valuation Reserve Default Component Column 1 Line 32

X X X X X X X

0.004 0.004 0.013 0.046 0.100 0.230 0.300

= = = = = = =

(14) Total Derivative Instruments Sum of Lines (7) through (13) (Column (1) should equal Asset Valuation Reserve Default Component Column 1 Line 33) (15) Total Miscellaneous Assets

Lines (6) + (14)

Denotes items that must be manually entered on the filing software. Š 2000 National Association of Insurance Commissioners

LR011

6/30/2000


Company Name

Confidential when Completed

NAIC Company Code

REPLICATION (SYNTHETIC ASSET) TRANSACTIONS AND MANDATORILY CONVERTIBLE SECURITIES (1)

(2)

(3)

(4)

RSAT Number

Type

CUSIP

Description of Assets

xxxxx

xxxxx

xxxxx

(5) NAIC Designation or Other Description of Asset

(6)

(7)

Value of Asset

RBC Requirement

(1) (2) (3) (4) (5) (6) (7) (8) (9) (10) (11) (12) (13) (14) (15) (16) (17) (18) (19) (20) (21) (22) (23) (24) (25) (26) (27) (28) (29) (30) (31) (32) (33) (34) (35) (9999999)

Total

xxxxx

Denotes items that must be manually entered on the filing software. Š 2000 National Association of Insurance Commissioners

LR012

6/30/2000


Company Name

Confidential when Completed

NAIC Company Code

REINSURANCE (1) Statement Value

Annual Statement Source (1) (2) (3) (4) (5) (6) (7)

Reinsurance Ceded† Recoverable on Paid Losses (Life) Recoverable on Paid Losses (A&H) Recoverable on Unpaid Losses (Life) Recoverable on Unpaid Losses (A&H) Unearned premiums (A&H) Other Reserve Credits (A&H) Reserve credit (Life)

(17) Total Reinsurance

RBC Subtotal

(2) Other than 100% Owned Affiliates

(4) RBC Requirement

Factor X X X X X X X

Statement Value

Reinsurance Payable Credit (13) Reinsurance in Unauthorized Companies (14) Funds Held in Unauthorized Reinsurers (15) Funds Held in Authorized Reinsurers (16) Other Reinsurance Recoverable or Reserves "Reestablished" on Page 3

(3)

Schedule S Part 2 Column 6 Line 0399999 Schedule S Part 2 Column 6 Line 0699999 Schedule S Part 2 Column 7 Line 0399999 Schedule S Part 2 Column 7 Line 0699999 Schedule S Part 3 Section 2 Column 8 Line 0399999 Schedule S Part 3 Section 2 Column 9 Line 0399999 Schedule S Part 3 Section 1 Column 8 Line 0399999 (1)

Reinsurance Assumed Credit (8) Affiliate Reserve Credit (Life) (9) Affiliate Reinsurance Payable (Life) (10) Reinsurance Assumed on Unearned Premiums (A&H) (11) Reinsurance Assumed Other Reserved Credits (A&H) (12) Reinsurance Assumed - Losses (A&H)

(2) 100% Owned Affiliates

0.008 0,008 0.008 0.008 0.008 0.008 0.008

= = = = = = =

(3)

RBC Subtotal

(4)

Factor

Schedule S Part 1 Section 1 Column 8 Line 0199999 Schedule S Part 1 Section 1 Column 10 Line 0199999 Schedule S Part 1 Section 2 Column 8 Line 0199999 Schedule S Part 1 Section 2 Column 9 Line 0199999 Schedule S Part 1 Section 2 Column 10 Line 0199999

X -0.008 = X -0.008 = X -0.008 =

Page 3 Column 1 Line 24.2

X -0.008 =

Page 3 Column 1 Line 24.3

X -0.008 =

Page 3 Column 1 Line 25 in part

X -0.008 =

Page 3 Column 1 Line 25 in part

X -0.008 =

RBC Requirement

X -0.008 = X -0.008 =

Sum of Lines (1) through (16)

Statement values should be net of policy loans if policy loans are part of the reinsurance transaction. Denotes items that must be manually entered on the filing software.

© 2000 National Association of Insurance Commissioners

LR013

6/30/2000


Company Name

Confidential when Completed

NAIC Company Code

OFF-BALANCE SHEET ITEMS (1) Annual Statement Source Noncontrolled Assets (1) Loaned to Others (2) Subject to Repurchase Agreements (3) Subject to Reverse Repurchase Agreements (4) Subject to Dollar Repurchase Agreements (5) Subject to Reverse Dollar Repurchase Agreements (6) Pledged as Collateral (7) Assets Placed Under Option Agreements (8) Letter Stock or Other Securities Restricted (9) Other (10) Less Noncontrolled Assets Funding Guaranteed Separate Accounts or Synthetic GIC's (11) Total Noncontrolled Assets

(12) (13) (14) (15) (16) (17) (18) (19)

Derivative Instruments Exchange Traded Off-Balance Sheet Exposure Class 1 Off-Balance Sheet Exposure Class 2 Off-Balance Sheet Exposure Class 3 Off-Balance Sheet Exposure Class 4 Off-Balance Sheet Exposure Class 5 Off-Balance Sheet Exposure Class 6 Total Derivative Instruments Off-Balance Sheet Exposure

Statement Value

(2) RBC Requirement

Factor

General Interrogatories Question Line 15 (b) Item i General Interrogatories Question Line 15 (b) Item ii General Interrogatories Question Line 15 (b) Item iii General Interrogatories Question Line 15 (b) Item iv General Interrogatories Question Line 15 (b) Item v General Interrogatories Question Line 15 (b) Item vi General Interrogatories Question Line 15 (b) Item vii General Interrogatories Question Line 15 (b) Item vii General Interrogatories Question Line 15 (b) Item ix Included in Lines (1) through (9)

Sum of Lines (1) through (9) less Line (10)

X

0.013

=

Schedule DB Part E Section 1 Column 6 Schedule DB Part E Section 1 Column 6 Schedule DB Part E Section 1 Column 6 Schedule DB Part E Section 1 Column 6 Schedule DB Part E Section 1 Column 6 Schedule DB Part E Section 1 Column 6 Schedule DB Part E Section 1 Column 6

X X X X X X X

0.004 0.004 0.013 0.046 0.100 0.230 0.300

= = = = = = =

X X X

0.013 0.013 0.000

= = =

Sum of Lines (11) through (18)

(20) Guarantees for Affiliates (21) Contingent Liabilities (22) Long Term Leases

Notes to Financial Statements Number 6e Notes to Financial Statements Number 17a Notes to Financial Statements Number 18

(23) Total Off-Balance Sheet Items

Lines (11) + (19) + (20) + (21) + (22)

Denotes items that must be manually entered on the filing software. Š 2000 National Association of Insurance Commissioners

LR014

6/30/2000


Company Name

Confidential when Completed

NAIC Company Code

HEALTH PREMIUMS

Annual Statement Source (1) (2) (3) (4) (5) (6) (7) (8) (9) (10) (11) (12) (13) (14) (15) (16) (17) (18) (19) (20) (21) (22)

Medical Insurance Premiums - Individual Morbidity Usual and Customary Major Medical and Hospital Medicare Supplement Dental and Vision Hospital Indemnity and Specified Disease AD&D (Maximum Retained Risk Per Life Other Accident Medical Insurance Premiums - Group and Credit Morbidity Usual and Customary Major Medical, Hospital Dental and Vision Stop Loss and Minimum Premium Medicare Supplement Hospital Indemnity and Specified Disease AD&D (Maximum Retained Risk Per Life Other Accident Federal Employee Health Benefit Plan Disability Income Premium Noncancellable Disability Income - Individual Morbidity Other Disability Income - Individual Morbidity Disability Income - Group and Credit Morbidity Long-Term Care Noncancellable Long-Term Care - Individual Morbidity Other Long-Term Care - Individual Morbidity Long-Term Care - Group Morbidity Health Premium With Limited Underwriting Risk ASC Business Reported as Revenue Premium Other Health Other Health

(23) Total Earned Premiums (Column (1) should equal Schedule H Part 1 Column 1 Line 2) †

‡ *

Earned Premium (Schedule H Part 1 Line 2 in part) Earned Premium (Schedule H Part 1 Line 2 in part) Earned Premium (Schedule H Part 1 Line 2 in part) Earned Premium (Schedule H Part 1 Line 2 in part) ) Earned Premium (Schedule H Part 1 Line 2 in part) Earned Premium (Schedule H Part 1 Line 2 in part) Earned Premium (Schedule H Part 1 Line 2 in part) Earned Premium (Schedule H Part 1 Line 2 in part) Earned Premium (Schedule H Part 1 Line 2 in part) Earned Premium (Schedule H Part 1 Line 2 in part) Earned Premium (Schedule H Part 1 Line 2 in part) ) Earned Premium (Schedule H Part 1 Line 2 in part) Earned Premium (Schedule H Part 1 Line 2 in part) Earned Premium (Schedule H Part 1 Line 2 in part)

(1) Statement Value

(2) RBC Requirement

Factor

X X X

† † † * ‡ 0.050

XXX XXX XXX = = =

X X X X

† † 0.250 † * ‡ 0.050 0.000

Earned Premium (Schedule H Part 1 Line 2 in part) Earned Premium (Schedule H Part 1 Line 2 in part) Earned Premium (Schedule H Part 1 Line 2 in part)

X X X

‡ ‡ ‡

= = =

Earned Premium (Schedule H Part 1 Line 2 in part) Earned Premium (Schedule H Part 1 Line 2 in part) Earned Premium (Schedule H Part 1 Line 2 in part)

X X X

‡ ‡ ‡

= = =

Earned Premium (Schedule H Part 1 Line 2 in part)

X

0.000

=

Earned Premium (Schedule H Part 1 Line 2 in part)

X

0.120

=

X

XXX XXX = XXX = = = =

Sum of Lines (1) through (22)

The premium amounts in these lines are transferred to LR016 Underwriting Risk – Experience Fluctuation Risk Lines (1.1) and (1.2) for the calculation of risk-based capital. The premium amounts are included here to assist in the balancing of total health premium. If managed care arrangements have been entered into, the company may also complete LR018 Underwriting (2), (3), (7), (8) or (10) on page LR015 Health Premiums, the company will also be directed to complete the Health Administrative Expense portion of LR024 Business Risk in the (C-4) portion of the formula. The two tiered calculation is illustrated in the risk-based capital instructions for LR015 Health Premiums. premium). Denotes items that must be manually entered on the filing software.

© 2000 National Association of Insurance Commissioners

LR015

6/30/2000


Company Name

Confidential when Completed

NAIC Company Code

UNDERWRITING RISK Experience Fluctuation Risk (1)

(1.1)

Line of Business Premium – Individual

(1.2) (1.3)

Comprehensive Medical

(2)

(3)

(4)

(5)

(6)

Medical Only

Medicare Supplement

Dental & Vision

Other

Total

XXX

XXX

Premium – Group

XXX

XXX

Premium – Total = Line (1.1) + Line (1.2)

XXX

(2)

Title XVIII-Medicare†

XXX

XXX

XXX

(3)

Title XIX-Medicaid†

XXX

XXX

XXX

(4)

Other Health Risk Revenue†

XXX

XXX

XXX

(5)

Underwriting Risk Revenue = Lines (1.3) + (2) + (3) + (4)

XXX

(6)

Net Incurred Claims

XXX

(7)

Fee-for-Service Offset†

XXX

(8)

Underwriting Risk Incurred Claims = Line (6) – Line (7)

XXX

(9)

Underwriting Risk Claims Ratio = Line (8) / Line (5)

XXX

XXX

XXX XXX XXX

XXX XXX XXX

XXX

(10.1)

Underwriting Risk Factor for Initial Amounts Of Premium‡

0.150

XXX

0.105

0.120

XXX

XXX

(10.2)

Underwriting Risk Factor for Excess of Initial Amount‡

0.090

XXX

0.067

0.076

XXX

XXX XXX

Composite Underwriting Risk Factor

XXX

XXX

(11)

Base Underwriting Risk RBC = Line (5) x Line (9) x Line (10.3)

XXX

XXX

(12)

Managed Care Discount Factor = LR018 Column (2) Line (11)

XXX

XXX

(13)

Base RBC After Managed Care Discount = Line (11) x Line (12)

XXX

XXX

(14)

RBC Adjustment For Individual = [{Line(1.1) x 1.2 + Line (1.2)} / Line (1.3) ] x Line (13)§

XXX

XXX

(15)

Maximum Per-Individual Risk After Reinsurance†

XXX

XXX

(16)

Alternate Risk Charge*

XXX

XXX

(17) (18)

Net Alternate Risk Charge£ Net Underwriting Risk RBC (Maximum of Line (14) or Line (17) )

XXX XXX

XXX XXX

(10.3)

† ‡ § *

£

XXX

XXX

Source is company records unless already included in premiums. For Comprehensive Medical the Initial Premium Amount is $25,000,000 or the amount in Line (1.3) if smaller. For Medicare Supplement and Dental & Vision, the Initial Premium Amount is $3,000,000 or the amount in Line (1.3) if smaller. Formula applies only to Column (1), for all other columns Line (14) should equal Line (13). The Line (16) Alternate Risk Charge is calculated as follows: $1,500,000 $50,000 $50,000 Maximum LESSER OF: or XXX or or XXX of 2 x Maximum 2 x Maximum 2 x Maximum Columns Individual Risk Individual Risk Individual Risk (1), (3) and (4) Applicable only if Line (16) for a column equals Line (16) for Column (6), otherwise zero. Denotes items that must be manually entered on the filing software.

© 2000 National Association of Insurance Commissioners

LR016

6/30/2000


Company Name

Confidential when Completed

NAIC Company Code

UNDERWRITING RISK - OTHER

(1) (2) (3)

(4)

Business with Rate Guarantees Between 15-36 Months Business with Rate Guarantees Over 36 Months Federal Employees Health Benefit Program (FEHBP) Claims Incurred Total, Other Underwriting Risk

Annual Statement Source Company Records Company Records Company Records

(1) Amount

(2) RBC Requirement

X X

Factor 0.024 0.064

= =

X

0.020

=

Lines (1) + (2) + (3)

Denotes items that must be manually entered on the filing software. Š 2000 National Association of Insurance Commissioners

LR017

6/30/2000


Company Name

Confidential when Completed

NAIC Company Code

UNDERWRITING RISK – MANAGED CARE CREDIT

Comprehensive Medical, Medicare Supplement and Dental Claim Payments

Annual Statement Source

(1) (2) (3) (4) (5) (6) (7) (8)

Category 0 - Arrangements not Included in Other Categories Category 1 - Payments Made According to Contractual Arrangements Category 2a - Subject to Withholds or Bonuses – Otherwise Category 0 Category 2b - Subject to Withholds or Bonuses – Otherwise Category 1 Category 3a - Capitated Payments Directly to Providers Category 3b - Capitated Payments to Regulated Intermediaries Category 3c - Capitated Payments to Non-Regulated Intermediaries Category 4 - Medical & Hospital Expense Paid as Salary to Providers

Company records Company records Company records Company records Company records Company records Company records Company records

(9)

Total Paid Claims

Sum of Lines (1) through (8)

(10) Weighted Average Managed Care Discount

Col (3) Line (9) / Col (2) Line (9)

(11) Weighted Average Managed Care Risk Adjustment Factor

1.0 - Col (3) Line (10)

† ‡

Withhold & bonus payments, prior year Withhold & bonuses available, prior year Managed Care Credit Multiplier – average withhold returned Withholds & bonuses available, prior year Claims payments subject to withhold, prior year Average withhold rate, prior year Managed Care Credit Discount Factor, Category 2

(3) Weighted Claims

Factor X X X X X X X X

0.000 0.150 † ‡ 0.600 0.600 0.600 0.750

= = = = = = = =

(1) Amount

Calculation of Category 2 Managed Care Factor (12) (13) (14) (15) (16) (17) (18)

(2) Paid Claims

Company Records Company Records Line (12) / Line (13) Line (13) Company Records Line (15) / Line (16) Minimum of 0.25 or Line (14) x Line (17)

Category 2 Managed Care Factor calculated on Line (18). Category 2 Managed Care Factor calculated on Line (18) with a minimum factor of 15 percent. Denotes items that must be manually entered on the filing software.

© 2000 National Association of Insurance Commissioners

LR018

6/30/2000


Company Name

Confidential when Completed

NAIC Company Code

HEALTH CLAIMS RESERVES (1) Annual Statement Source (1) (2) (3) (4) (5) (6) (7) (8)

Individual Claim Reserves Exhibit 9 Collectively Renewable Claim Reserves Exhibit 9 Non-Cancellable Claim Reserves Exhibit 9 Guaranteed Renewable Claim Reserves Exhibit 9 Non-Renewable for Stated Reason Only Claim Reserves Exhibit 9 Other Accident Only Claim Reserves Exhibit 9 All Other Claim Reserves Modified Coinsurance Assumed Reserves Less Modified Coinsurance Ceded Reserves

(9) Total Individual Claim Reserves

(10) (11) (12) (13)

Group and Credit Claim Reserves Exhibit 9 Group Claim Reserves Exhibit 9 Credit Claim Reserves Modified Coinsurance Assumed Reserves Less Modified Coinsurance Ceded Reserves

Factor

Exhibit 9 Column 4 Line 16 Exhibit 9 Column 5 Line 16 Exhibit 9 Column 6 Line 16 Exhibit 9 Column 7 Line 16 Exhibit 9 Column 8 Line 16 Exhibit 9 Column 9 Line 16 Schedule S Part 1 Section 2 Column 11, in part † Schedule S Part 3 Section 2 Column 12, in part † Lines (1) + (2) + (3) + (4) + (5) + (6) + (7) - (8)

X

0.050

=

X

0.050

=

Exhibit 9 Column 2 Line 16 Exhibit 9 Column 3 Line 16 Schedule S Part 1 Section 2 Column 11, in part † Schedule S Part 3 Section 2 Column 12, in part †

(14) Total Exhibit 9 Group and Credit Claim Reserves

Lines (10) + (11) + (12) - (13)

(15) Total Claim Reserves

Lines (9) + (14)

(16) Total Health RBC

LR015 Health Premiums Column (2) Line (23) + LR016 Underwriting Risk Experience Fluctuation Risk Column (6) Line (18) + LR017 Underwriting Risk Other Column (2) Line (4) + LR019 Health Claim Reserves Column (2) Line (15)

Statement Value

(2) RBC Requirement

Include only the portion which relates to claim reserves that, if written on a direct basis, would be included on Exhibit 9. Denotes items that must be manually entered on the filing software.

© 2000 National Association of Insurance Commissioners

LR019

6/30/2000


Company Name

Confidential when Completed

NAIC Company Code

LIFE INSURANCE (1) Annual Statement Source (1) (2) (3) (4) (5) (6) (7) (8)

Individual & Industrial Net Amount at Risk Ordinary Life In Force Less Ordinary Life Reserves Plus Industrial Life In Force Less Industrial Life Reserves Less Separate Accounts Less Modified Coinsurance Assumed Reserves Plus Modified Coinsurance Ceded Reserves Total Individual and Industrial Net Amount at Risk

(9) (10) (11) (12) (13) (14) (15) (16) (17) (18) (19)

Group and Credit Net Amount at Risk Group Life In Force Less Group FEGLI Less Group SGLI Less Group Life Reserves Plus Credit Life In Force Less Credit FEGLI Less Credit SGLI Less Credit Life Reserves Less Modified Coinsurance Assumed Reserves Plus Modified Coinsurance Ceded Reserves Total Group and Credit Net Amount at Risk

(20)

FEGLI/SGLI Life In Force

(21) Total Life

† ‡

Statement Value

Exhibit of Life Insurance Column 4 Line 22 x 1000 Exhibit 8 Column 4 Line 0199999 Exhibit of Life Insurance Column 2 Line 22 x 1000 Exhibit 8 Column 3 Line 0199999 Separate Accounts Exhibit 6 Column 3 Line 0199999 Schedule S Part 1 Section 1 Column 11, in part ‡ Schedule S Part 3 Section 1 Column 13, in part ‡ Lines (1) + (3) + (7) - (2) - (4) - (5) - (6)

Exhibit of Life Insurance Column 9 Line 22 x 1000 Exhibit of Life Insurance Column 4 Line 36 x 1000 Exhibit of Life Insurance Column 4 Line 37 x 1000 Exhibit 8 Column 6 Line 0199999 Exhibit of Life Insurance Column 6 Line 22 x 1000 Exhibit of Life Insurance Column 2 Line 36 x 1000 Exhibit of Life Insurance Column 2 Line 37 x 1000 Exhibit 8 Column 5 Line 0199999 Schedule S Part 1 Section 1 Column 11, in part ‡ Schedule S Part 3 Section 1 Column 13, in part ‡ Lines (9) + (13) + (18) - (10) - (11) - (12) - (14) - (15) - (16) - (17) Exhibit of Life Insurance Column 2 and 4 Line 36 and 37 x 1000

(2) RBC Requirement

Factor

X

=

X

=

X

0.0008

=

Lines (8) + (19) + (20)

The tiered calculation is illustrated in the Life Insurance section of the risk-based capital instructions. Include only the portion which relates to policy reserves that, if written on a direct basis, would be included on Exhibit 8. Denotes items that must be manually entered on the filing software.

© 2000 National Association of Insurance Commissioners

LR020

6/30/2000


Company Name

Confidential when Completed

NAIC Company Code

PREMIUM STABILIZATION RESERVES (1)

(2) (3) (4) (5)

Annual Statement Source Group and Credit Life and Health Reported Premium Stabilization Reserves Stabilization Reserves and Experience Rating Refunds included Page 3 Column 1 Line 10.3 in part in Line 10.3 Provision for Experience Rating Refunds Page 3 Column 1 Line 11.2 Reserve for Group Rate Credits Exhibit 9 Column 2 Line 5 Reserve for Credit Rate Credits Exhibit 9 Column 3 Line 5 Premium Stabilization Reserves Page 3 Column 1 Part 25 in part

(6)

Total of Preliminary Premium Stabilization Reserve Credit

(7) (8)

Group & Credit Life and Health Risk-Based Capital Life Health

(9)

Maximum Risk-Based Capital

(1)

(10) Final Premium Stabilization Reserve

Statement Value

(2) RBC Requirement

Factor X

0.500

=

X X X X

0.500 0.500 0.500 0.500

= = = =

X -1.000

=

Sum of Lines (1) through (5)

LR020 Life Insurance Column (2) Line (19) LR019 Health Claim Reserves Column (2) Line (14) + LR015 Health Premiums Column (2) Lines (9), (11), (12), (13), (17) and (20) + [LR016 Underwriting Risk Experience Fluctuation Risk Column (6) Line 18 x Line (1.2) / Line (1.3) ] Lines (7) + (8) Column (2) Line (6), but not more than Column (1) Line (9)

Denotes items that must be manually entered on the filing software. Š 2000 National Association of Insurance Commissioners

LR021

6/30/2000


Company Name

Confidential when Completed

NAIC Company Code

INTEREST RATE RISK (1) (1.1) Unqualified Section 8 Actuarial Opinion? ["Yes" or "No" in Column (1)] (1.2) Cash Flow Testing (CFT) on Annuities or Single Premium Life? ["Yes" or "No" in Column (1)] (1.3) If Line (1.2) is "Yes", is the Appointed Actuary C-3 Assumption Statement Attached? ["Yes" or "No" in Column (1)]

(2) (3) (4) (5.1) (5.2) (5.3) (5.4) (5.5) (6)

RESERVES ON CERTAIN ANNUITIES AND SINGLE PREMIUM LIFE INSURANCE THAT WERE CASH FLOW TESTED FOR RESERVE ADEQUACY (See Appendix 1 of the instructions for more details.) Annual Statement Source Low Risk Category that were Cash Flow Tested for Reserve Adequacy Annuity Reserve with Market Value Adjustment (excluding unitized separate Notes to Financial Statements Item 12 Line 1.1, accounts)* in part‡ Annuity Reserve not Withdrawable (excluding structured settlements)* Notes to Financial Statements Item 12 Line 2, in part‡ Guaranteed Investment Contract (GIC) Reserve within 1 Year of Maturity£ Notes to Financial Statements Item 12 Various Lines, in part‡ Single Premium Life Insurance Reserves Net of Reinsurance Exhibit 8 Section A Column 2 Line 0199999, in part Less Single Premium Life Insurance Reserves Policy Loans Page 2 Line 5, in part Plus Modified Coinsurance Assumed Single Premium Life Reserves net of Schedule S Part 1 Section 1 Column 11, Modified Coinsurance Assumed Policy Loans in part‡ Less Modified Coinsurance Ceded Single Premium Life Reserves net of Modified Schedule S Part 3 Section 1 Column 13, Coinsurance Ceded Policy Loans in part‡ Single Premium Life Insurance Reserves Line (5.1) - (5.2) + (5.3) - (5.4) Total Low Risk Lines (2) + (3) + (4) + (5.5)

(7)

Medium Risk Category that were Cash Flow Tested for Reserve Adequacy Annuity Reserve at Book Value Less Surrender Charge of 5 Percent or More*

(8)

Exhibit 10 Reserve not Included in Notes to Financial Statements Item 12 §

(9)

Structured Settlements

(10) Additional Actuarial Reserves for Annuities and Single Premium Life Asset/Liability Analysis (11) Total Medium Risk

Notes to Financial Statements Item 12 Line 1.2, in part‡ Exhibit 10 Line 19 amounts not included elsewhere in Interest Rate Risk (C-3)‡ Notes to Financial Statements Item 12 Line 2, in part‡ Exhibit 8 Column 2 Line 0700004, in part

(2) Statement Value

Factor

(3) RBC Requirement

X 0.0075 or 0.0050† =

use .0115or.0077

X 0.0075 or 0.0050† =

for each of

X 0.0075 or 0.0050† =

these

X 0.0075 or 0.0050† =

and this one

X 0.0150 or 0.0100† = use 0.0231 or .0154 X 0.0150 or 0.0100† =

for each of

X 0.0150 or 0.0100† =

these

0.0150 or 0.0100†

and this one

Sum of Lines (7) through (10)

† ‡ § * £

factor, depending on the answer to Line (1.1). Net of reinsurance, less policy loans, plus modified coinsurance assumed reserves, less modified coinsurance ceded reserves. Excluding any non-policyholder reserves (e.g., reserves that are not related to specific policies). Excluding GICs within 1 year of maturity. Includes GICs within 1 year of maturity subtracted elsewhere. Denotes items that must be manually entered on the filing software.

© 2000 National Association of Insurance Commissioners

LR022

6/30/2000


Company Name

Confidential when Completed

NAIC Company Code

INTEREST RATE RISK (Continued)

Annual Statement Source High Risk Category that were Cash Flow Tested for Reserve Adequacy (12) Annuity Reserve at Book Value Without Adjustment (minimal or no charge or adjustment)* (13) Debt with GIC-like Characteristics (see Appendix 1 & 1b instructions) (14) Total High Risk

Notes to Financial Statements Item 12 Line 1.5, in part‡ Company records Line (12) + (13)

Synthetic GIC's (15) Synthetic GIC's C-3 Requirement

Company records

Callable Assets (16) Callable Assets Assigned to Products Categorized Above

Company records

(17) Subtotal of Factor Based RBC For Products Categorized Above

Lines (6) + (11) + (14) + (15)

(2) Statement Value

Factor

(3) RBC Requirement

X 0.0300 or 0.0200† = use .0462or .0308

ALL OTHER RESERVES (exclude statement amounts included in Lines (2) to (17) above) Low Risk Category (18) Annuity Reserve with Market Value Adjustment (excluding unitized separate accounts and eligible experience rated pension and separate accounts with guarantees)* (19) Annuity Reserve not Withdrawable (excluding structured settlements and eligible experience rated pension and separate accounts with guarantees)* (20) Guaranteed Investment Contract (GIC) Reserve within 1 Year of Maturity£ (21.1) Life Insurance Reserves Net of Reinsurance (21.2) Less Life Insurance Reserves Policy Loans (21.3) Plus Modified Coinsurance Assumed Reserves net of Modified Coinsurance Assumed Policy Loans (21.4) Less Modified Coinsurance Ceded Reserves net of Modified Coinsurance Ceded Policy Loans (21.5) Life Insurance Reserves (22) Total Low Risk

Notes to Financial Statements Item 12 Line 1.1, in part‡

X 0.0075 or 0.0050† = use .0115 or .0077

Notes to Financial Statements Item 12 Line 2, in part‡ Notes to Financial Statements Item 12 Various Lines, in part‡ Exhibit 8 Section A Column 2 Line 0199999, in part Page 2 Line 5, in part Schedule S Part 1 Section 1 Column 11, in part‡ Schedule S Part 3 Section 1 Column 13, in part‡ Line (22.1) - (22.2) + (22.3) - (22.4) Lines (19) + (20) + (21) + (22.5)

X 0.0075 or 0.0050† = for each X 0.0075 or 0.0050† = of these

X 0.0075 or 0.0050† = and this one too

† ‡ § * £

factor, depending on the answer to Line (1.1). Net of reinsurance, less policy loans, plus modified coinsurance assumed reserves, less modified coinsurance ceded reserves. Excluding any non-policyholder reserves (e.g., reserves that are not related to specific policies). Excluding GICs within 1 year of maturity. Includes GICs within 1 year of maturity subtracted elsewhere. Denotes items that must be manually entered on the filing software.

© 2000 National Association of Insurance Commissioners

LR022

6/30/2000


Company Name

Confidential when Completed

NAIC Company Code

INTEREST RATE RISK (Continued)

Annual Statement Source Medium Risk Category (23) Annuity Reserve at Book Value Less Surrender Charge of 5 Percent or More*

(26) Additional Actuarial Reserves - Asset/Liability Analysis (27) Total Medium Risk

Notes to Financial Statements Item 12 Line 1.2, in part‡ Exhibit 10 Line 19 amounts not included elsewhere in Interest Rate Risk (C-3)‡ Notes to Financial Statements Item 12 Line 2, in part‡ Exhibit 8 Column 2 Line 0700004, in part Sum of Lines (23) through (26)

High Risk Category (28) Annuity Reserve at Book Value Without Adjustment (minimal or no charge or adjustment)* (29) Total High Risk

Notes to Financial Statements Item 12 Line 1.5, in part‡ Line (28)

Synthetic GIC's (30) Synthetic GIC's C-3 Requirement

Company records

(24) Exhibit 10 Reserve not Included in Notes to Financial Statements Item 12 § (25) Structured Settlements

(2) Statement Value

Factor

(3) RBC Requirement

X 0.0150 or 0.0100† = use .0231 or .0154 X 0.0150 or 0.0100† = for X 0.0150 or 0.0100† = each X 0.0150 or 0.0100† = of these

X 0.0300 or 0.0200† = use .0462 or .0308

RBC x 1.000 (less "haircut")

Callable Assets (31) Callable Assets Not Allocated to Line (16). Include Callable Assets Allocated to

Company records

Surplus (32) Interest Rate Risk Based Completely on Factors

Lines (16) + (17) + (22) + (27) + (29) + (30) + (31)

(33) Cash Flow Scenario Testing Interest Rate Risk (If C-3 Cash Flow Scenario Testing

Company records

Scenario Testing

Exemption Worksheet Line (11) = "Yes" or Line (19) = "Yes" then calculate the cash flow scenario testing interest rate risk for annuities and single premium life products that were cash flow tested) (34) Total Interest Rate Risk

If Line (33) = 0, then Line (34) = Line (32). Otherwise, Line (34) = Line (32) + (33) - (16) - (17), subject to a maximum 2 times Line (32) and a minimum of 0.5 times Line (32)

† ‡ § * £

factor, depending on the answer to Line (1.1). Net of reinsurance, less policy loans, plus modified coinsurance assumed reserves, less modified coinsurance ceded reserves. Excluding any non-policyholder reserves (e.g., reserves that are not related to specific policies). Excluding GICs within 1 year of maturity. Includes GICs within 1 year of maturity subtracted elsewhere. Denotes items that must be manually entered on the filing software.

© 2000 National Association of Insurance Commissioners

LR022

6/30/2000


Company Name

Confidential when Completed

NAIC Company Code

HEALTH CREDIT RISK

Annual Statement Source (1)

Capitations to Intermediaries Total Capitations Paid Directly to Providers

(2) (3)

Less Secured Capitations to Providers Net Capitations to Providers Subject to Credit Risk Charge

(1) Amount

(2) RBC Requirement

Factor

LR018 Underwriting Risk Managed Care Credit Column (1) Line (5) Company Records † Line (1) – Line (2)

X

0.020

=

(4) Total Capitations to Intermediaries (5) Less Secured Capitations to Intermediaries (6) Net Capitations to Intermediaries Subject to Credit Risk Charge

LR018 Column (1) Lines (6) + (7) Company Records † Line(4) – Line (5)

X

0.040

=

(7)

Line (3) + Line (6)

Capitation Credit Risk RBC

Amounts entered on capitations worksheets. Denotes items that must be manually entered on the filing software.

© 2000 National Association of Insurance Commissioners

LR023

6/30/2000


Company Name

Confidential when Completed

NAIC Company Code

BUSINESS RISK (1) Annual Statement Source Life Insurance Premiums (1) Total Life Premiums (2) Less American Samoa Life Premiums (3) Less Guam Life Premiums (4) Less Puerto Rico Life Premiums (5) Less U.S. Virgin Islands Life Premiums (6) Less Canada Life Premiums (7) Less Other Alien Life Premiums (8) Subtotal Net Life Premiums (9) Plus Foreign Variable and Other Life Premiums (10) Less Total Variable and Other Life Premiums (11) Net Life Premiums

Statement Value

(2) RBC Requirement

Factor

Schedule T Column 3 Line 58 Schedule T Column 3 Line 52 Schedule T Column 3 Line 53 Schedule T Column 3 Line 54 Schedule T Column 3 Line 55 Schedule T Column 3 Line 56 Schedule T Column 3 Line 57 Line (1) less the Sum of Lines (2) through (7) See Instructions† See Instructions† Line (8) plus Line (9) less Line (10)

X 0.0308

=

(12) (13) (14) (15) (16) (17) (18) (19) (20) (21) (22)

Annuity Considerations Total Annuity Considerations Less American Samoa Annuity Considerations Less Guam Annuity Considerations Less Puerto Rico Annuity Considerations Less U.S. Virgin Islands Annuity Considerations Less Canada Annuity Considerations Less Other Alien Annuity Considerations Subtotal Net Annuity Considerations Plus Foreign Variable and Other Life Premiums Less Total Variable and Other Life Premiums Net Annuity Considerations

Schedule T Column 4 Line 58 Schedule T Column 4 Line 52 Schedule T Column 4 Line 53 Schedule T Column 4 Line 54 Schedule T Column 4 Line 55 Schedule T Column 4 Line 56 Schedule T Column 4 Line 57 Line (12) less the Sum of Lines (13) through (18) See Instructions† See Instructions† Line (19) plus Line (20) less Line (21)

X 0.0308

=

(23) (24) (25) (26) (27) (28) (29) (30) (31) (32) (33)

Accident and Health Premiums Total Accident and Health Premiums Less American Samoa Accident and Health Premiums Less Guam Accident and Health Premiums Less Puerto Rico Accident and Health Premiums Less U.S. Virgin Islands Accident and Health Premiums Less Canada Accident and Health Premiums Less Other Alien Accident and Health Premiums Subtotal Net Accident and Health Premiums Plus Foreign Variable and Other Life Premiums Less Total Variable and Other Life Premiums Net Accident and Health Premiums

Schedule T Column 5 Line 58 Schedule T Column 5 Line 52 Schedule T Column 5 Line 53 Schedule T Column 5 Line 54 Schedule T Column 5 Line 55 Schedule T Column 5 Line 56 Schedule T Column 5 Line 57 Line (23) less the Sum of Lines (24) through (29) See Instructions† See Instructions† Line (30) plus Line (31) less Line (32)

X 0.0077

=

Enter amounts only if included in Schedule T Column 3 (life), Column 4 (annuity) or Column 5 (accident and health). Denotes items that must be manually entered on the filing software.

© 2000 National Association of Insurance Commissioners

LR024

6/30/2000


Company Name

Confidential when Completed

NAIC Company Code

BUSINESS RISK (CONTINUED) (1) Annual Statement Source Separate Account Liabilities (34) Total Liabilities from Separate Accounts Statement (35) Transfers to Separate Accounts Due or Accrued (36) Total Separate Account Liabilities

Page 3 Column 1 Line 27 Page 3 Column 1 Line 13A Line (34) plus Line (35)

(37) Business Risk (C-4a)

Lines (11) + (22) + (33) + (36)

(38) (39) (40) (41) (42) (43) (44) (45) (46) (47) (48)

(49) (50) (51) (52) (53)

Factor

X 0.0008

=

X X X X

.0.0308 0.0308 0.0154 0.0154

= = = =

X 0.0154

=

Administrative Expenses for Certain A&H Coverages LR015 Health Premiums Column (1) Line (23) Total Accident and Health Premiums Accident and Health Premiums from Underwriting Risk LR016 Underwriting Risk Column (6) Line (1.3) Accident and Health Premiums Factor Line (39) / Line (38) Exhibit 5 Administrative Expenses for Health Insurance Exhibit 5 Col. 2 Line 10 Exhibit 6 Administrative Expenses for Health Insurance Exhibit 6 Col. 2 Line 7 Less Administrative Expenses for Administrative Service Contracts (ASC) Company Records‡ Less Administrative Expenses for Administrative Services Only (ASO) Business Company Records‡ Less Administrative Expenses for Commissions and Premium Taxes Included in Exhibit 5 Col. 2 and Exhibit 6 Col. 2‡ Net Administrative Expenses Lines (41) + (42) - (43) - (44) - (45) Composite Health Administrative Expense Risk Factor 7% of Line (39) up to $25 million+ 4% of excess/Line (39) Administrative Expense Component for Health Line (46) x factor Line (40) x factor Line (47) Health ASO/ASC Administrative Expenses for ASC Business Company Records§ Administrative Expenses for ASO Business Company Records§ ASC Claims Reported as Incurred Claims Company Records Other Medical Costs Paid through ASC Arrangements Company Records Fee-for-Service Received from Managed Care Organizations (MCO’s) Company Records

(54) Business Risk (C-4b)

‡ §

Statement Value

(2) RBC Requirement

Column (2) Lines (48) + (49) + (50) + (51) + (52) + (53)

Include only amounts from Exhibit 5 Column 2 or Exhibit 6 Column 2. Line (49) should be greater than or equal to Line (43). Line (50) should be greater than or equal to Line (44). Denotes items that must be manually entered on the filing software.

© 2000 National Association of Insurance Commissioners

LR024

6/30/2000


Company Name

Confidential when Completed

NAIC Company Code

CALCULATION OF AUTHORIZED CONTROL LEVEL RISK-BASED CAPITAL

Source (1) (2) (3) (4) (5) (6) (7)

Asset Risk - Affiliated Amounts (C-0) Affiliated US Property-Casualty Insurers Directly Owned Affiliated US Life Insurers Directly Owned Affiliated US Property-Casualty Insurers Indirectly Owned Affiliated US Life Insurers Indirectly Owned Affiliated Alien Life Insurers - Canadian Affiliated Alien Life Insurers - All Others Off-Balance Sheet Items

(8) Total (C-0)

(9) (10) (11) (12) (13) (14) (15) (16) (17) (18) (19) (20) (21) (22) (23) (24) (25) (26) (27) (28)

Asset Risk - All Other (C-1) Bonds after Size Factor Mortgages (including past due and unpaid taxes) Unaffiliated Preferred Stock and Common Stock Affiliated Preferred Stock and Common Stock - Investment Subsidiaries Affiliated Preferred Stock and Common Stock - Holding Company in Excess of Indirect Subsidiaries Affiliated Preferred Stock and Common Stock - Parent Affiliated Preferred Stock and Common Stock - Property and Casualty Insurers not Subject to Risk-Based Capital Affiliated Preferred Stock and Common Stock - Life Insurers not Subject to Risk-Based Capital Affiliated Preferred Stock and Common Stock - All Other Affiliated Preferred Stock and Common Stock - Publicly Traded Insurers Held at Market Value (excess of statement value over book value) Separate Accounts with Guarantees Synthetic GIC's (C-1) Surplus in Non-Guaranteed Separate Accounts Real Estate (gross of encumbrances) Schedule BA Real Estate (gross of encumbrances) Other Long-Term Assets Schedule BA Mortgages Concentration Factor Miscellaneous Replication Transactions and Manditorily Convertible Securities

(1) RBC Requirement

LR033 Summary for Affiliated Investments Column (4) Line (1) LR033 Summary for Affiliated Investments Column (4) Line (2) LR033 Summary for Affiliated Investments Column (4) Line (3) LR033 Summary for Affiliated Investments Column (4) Line (4) LR033 Summary for Affiliated Investments Column (4) Line (7) LR033 Summary for Affiliated Investments Column (4) Line (8) LR014 Off-Balance Sheet Items Column (2) Line (23) Sum of Lines (1) through (7)

LR002 Bonds Column (2) Line (26) LR004 Mortgages Column (6) Line (22) LR005 Unaffiliated Preferred and Common Stock Column (4) Line (17) LR033 Summary for Affiliated Investments Column (4) Line (5) LR033 Summary for Affiliated Investments Column (4) Line (6) LR033 Summary for Affiliated Investments Column (4) Line (9) LR033 Summary for Affiliated Investments Column (4) Line (10) LR033 Summary for Affiliated Investments Column (4) Line (11) LR033 Summary for Affiliated Investments Column (4) Line (12) LR033 Summary for Affiliated Investments Column (4) Line (13)

(29) Reinsurance

LR006 Separate Accounts Column (2) Line (7) LR006 Separate Accounts Column (2) Line (8) LR006 Separate Accounts Column (2) Line (13) LR007 Real Estate Column (3) Line (16) LR007 Real Estate Column (3) Line (23) LR008 Other Long-Term Assets Column (4) Line (42) LR009 Schedule BA Mortgages Column (6) Line (11) LR010 Asset Concentration Factor Column (6) Line (40) Grand Total Page LR011 Miscellaneous Assets Column (2) Line (15) LR012 Replication (Synthetic Asset) Transactions and Mandatorily Convertible Securities Column (6) Line (9999999) LR013 Reinsurance Column (4) Line (17)

(30) Total (C-1)

Sum of Lines (9) through (29)

Denotes items that must be manually entered on the filing software.

Š 2000 National Association of Insurance Commissioners

LR025

6/30/2000


Company Name

Confidential when Completed

NAIC Company Code

CALCULATION OF AUTHORIZED CONTROL LEVEL RISK-BASED CAPITAL (CONTINUED)

Source (31) (32) (33) (34)

Insurance Risk (C-2) Individual and Industrial Life Insurance Group and Credit Life Insurance and FEGI/SGLI Total Health Insurance Premium Stabilization Reserve Credit

(1) RBC Requirement

LR020 Life Insurance Column (2) Line (8) LR020 Life Insurance Column (2) Lines (19) and (20) LR019 Health Claim Reserves Column (2) Line (16) LR021 Premium Stabilization Reserves Column (2) Line (10)

(35) Total (C-2)

Sum of Lines (31) through (34)

Interest Rate Risk (C-3a) (36) Total Interest Rate Risk

LR022 Interest Rate Risk Column (3) Line (34)

Health Credit Risk (C-3b) (37) Total Health Credit Risk

LR023 Health Credit Risk Column (2) Line (7)

Business Risk (C-4) (38) Premium Component (39) Liability Component (40) Subtotal Business Risk (C-4a)

LR024 Business Risk Column (2) Lines (11) + (22) + (33) LR024 Business Risk Column (2) Line (36) Lines (38) + (39)

(41) Health Administrative Expense Component of Business Risk (C-4b)

LR024 Business Risk Column (2) Line (54)

Total Risk-Based Capital After Covariance (42) C-0 + C-4a + Square Root of [(C-1 + C-3a)² + (C-2)² + (C-3b)² + (C-4b)²]

REPORT AMOUNT ON PARENT COMPANY'S RISK-BASED CAPITAL IF APPLICABLE

Authorized Control Level Risk-Based Capital (After Covariance Adjustment) (43) Total Risk-Based Capital After Covariance Times Fifty Percent

Line (42) x 0.50

42a Tax Sensitivity Test -RBC 43a Tax Sensitivity Test -RBC

Line 42 calculated on a pretax basis Line 43 calculated on a pretax basis

Denotes items that must be manually entered on the filing software.

© 2000 National Association of Insurance Commissioners

LR025

6/30/2000


Company Name

Confidential when Completed

NAIC Company Code

CAPITAL NOTES BEFORE LIMITATION

Years to Maturity at the Time of the Statement

(1) Original Principal Amount

(2) Limitation on Principal Amount

Limitation Factor

(1) (2) (3) (4) (5) (6)

Capital Notes Maturing 15 Years or less from the Year of Issue Greater than 0 and less that or equal to 1 Greater than 1 and less that or equal to 2 Greater than 2 and less that or equal to 3 Greater than 3 and less that or equal to 4 Greater than 4 and less that or equal to 5 Greater than 5

X X X X X X

0.0 0.2 0.4 0.6 0.8 1.0

= = = = = =

(7) (8) (9) (10) (11) (12) (13) (14) (15) (16) (17)

Capital Notes Maturing more than 15 Years from the Year of Issue Greater than 0 and less than or equal to 1 Greater than 1 and less than or equal to 2 Greater than 2 and less than or equal to 3 Greater than 3 and less than or equal to 4 Greater than 4 and less than or equal to 5 Greater than 5 and less than or equal to 6 Greater than 6 and less than or equal to 7 Greater than 7 and less than or equal to 8 Greater than 8 and less than or equal to 9 Greater than 9 and less than or equal to 10 Greater than 10

X X X X X X X X X X X

0.0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9 1.0

= = = = = = = = = = =

(3) Current Principal Amount

(4) Credit to Total Adjusted Capital †

(18) Credit for Capital Notes Before Limitation (sum of lines (1) through (17))

Column (4) is calculated as the lesser of Column (2) or Column (3). Denotes items that must be manually entered on the filing software.

© 2000 National Association of Insurance Commissioners

LR026

6/30/2000


Company Name

Confidential when Completed

NAIC Company Code

CALCULATION OF TOTAL ADJUSTED CAPITAL (1) Statement Value

Annual Statement Source

(2) Adjusted Capital

Factor

(1) (2) (3) (4)

Company Amounts Capital and Surplus Asset Valuation Reserve Dividends Apportioned for Payment Dividends Not Yet Apportioned

Page 3 Column 1 Line 38 Page 3 Column 1 Line 24.1 Page 3 Column 1 Line 7.1 Page 3 Column 1 Line 7.2

X X X X

1.000 1.000 0.500 0.500

= = = =

(5) (6)

Life Subsidiary Company Amounts† Asset Valuation Reserve Dividend Liability

Subsidiaries' Annual Statement Page 3 Column 1 Line 24.1‡ Subsidiaries' Annual Statement Page 3 Column 1 Line 7.1 + Line 7.2‡

X X

1.000 0.500

= =

(7)

Property and Casualty Amounts Non-Tabular discount

Included in Subsidiaries' Annual Statement Page 3 Column 1 Line 1 + 2‡

X

1.000

=

(8)

Total Adjusted Capital Before Capital Notes

Sum of Lines (1) through (6) less Line (7)

Credit for Capital Notes Surplus Notes Limitation on Capital Notes Capital Notes Before Limitation Credit for Capital Notes

Page 3 Column 1 Line 32 0.5 x [Line (8) - Line (9.1)] - Line (9.2), but not less than 0 LR026 Capital Notes Before Limitation Column (5) Line (18) Lesser of Column (1) Line (9.2) or Line (9.3)

(9.1) (9.2) (9.3) (9.4)

(10) Total Adjusted Capital

Line (8) + Line (9.4)

-(11) Tax Sensitivity Test -TAC

Line (10) less [LR032 Line 11.1 = Line 11.2]

† ‡

Including subsidiaries owned by holding companies. Multiply statement value by percent of ownership. Denotes items that must be manually entered on the filing software.

© 2000 National Association of Insurance Commissioners

LR027

6/30/2000


Company Name

Confidential when Completed

NAIC Company Code

RISK-BASED CAPITAL LEVEL OF ACTION

Source (1)

Total Adjusted Capital - REPORT AMOUNT IN FIVE-YEAR HISTORICAL DATA PAGE 22 COLUMN 1 LINE 27

LR027 Calculation of Total Adjusted Capital Column (2) Line (10)

(2)

Trigger Points for Level of Regulatory Action: Company Action Level = 200% of Authorized Control Level Risk-Based Capital

(3)

Regulatory Action Level = 150% of Authorized Control Level Risk-Based Capital

1.5 times LR025 Calculation of Total Authorized Control Level RiskBased Capital Column (1) Line (43)

(4)

Authorized Control Level Risk-Based Capital - REPORT AMOUNT IN FIVE-YEAR HISTORICAL DATA PAGE 22 COLUMN 1 LINE 28

1.0 times LR025 Calculation of Total Authorized Control Level RiskBased Capital Column (1) Line (43)

(5)

Mandatory Control Level = 70% of Authorized Control Level Risk-Based Capital

0.7 times LR025 Calculation of Total Authorized Control Level RiskBased Capital Column (1) Line (43)

(6)

Level of Action†:

1a-6a Tax Sensitivity Test Redo Lines 1 through 6 on a pretax basis

(1) RBC Amount

2.0 times LR025 Calculation of Total Authorized Control Level RiskBased Capital Column (1) Line (43)

Same as above for lines 1 throough 6.

If Total Adjusted Capital Line (1) exceeds Company Action Level Risk-Based Capital Line (2), None will be indicated (unless the Trend Test triggers Company Action Level). Otherwise, the appropriate level of action will be indicated. Denotes items that must be manually entered on the filing software.

© 2000 National Association of Insurance Commissioners

LR028

6/30/2000


Company Name

Confidential when Completed

NAIC Company Code

TREND TEST Source Criteria for Applying Trend Test (1) Authorized Control Level Risk-Based Capital (2) Trend Test Safe Harbor

LR025 Calculation of Authorized Control Level Risk-Based Capital Column (1) Line (43) 2.5 x Line (1)

(3) Total Adjusted Capital

LR027 Calculation of Total Adjusted Capital Line (10)

(4) (5) (6) (7)

Trend Test Data First Prior Year Total Adjusted Capital First Prior Year Authorized Control Level Risk-Based Capital Third Prior Year Total Adjusted Capital Third Prior Year Authorized Control Level RBC

Five-Year Historical Data Page 22 Column 2 Line 27 Five-Year Historical Data Page 22 Column 2 Line 28 Five-Year Historical Data Page 22 Column 4 Line 27 Five-Year Historical Data Page 22 Column 4 Line 28

(8) (9) (10) (11) (12) (13) (14) (15)

Trend Test Calculation (only if applicable†) Current Year Margin First Prior Year Margin Third Prior Year Margin Decrease in Margin from First Prior Year Decrease in Margin from Third Prior Year Average decrease in Last Three Years Marginal Difference Total Adjusted Capital Less Margin Difference

Line (3) - Line (1) Line (4) - Line (5) Line (6) - Line (7) Line (9) - Line (8) (use zero if negative) Line (10) - Line (8) (use zero if negative) 1/3 of Line (12) Greater of Line (11) and Line (13) Line (3) - Line (14)

(16) Level of Risk-Based Capital‡

† ‡

(1) Amount

1.9 x Line (1)

The Trend Test applies only if Total Adjusted Capital Line (3) is less than the Trend Test Safe Harbor Line (2) and the LR028 Risk-Based Capital Level of Action Line (6) is “None”. If Line (15) is less than Line (16), the company triggers regulatory attention at the Company Action Level based on the trend test. Denotes items that must be manually entered on the filing software.

© 2000 National Association of Insurance Commissioners

LR029

6/30/2000


Company Name

Confidential when Completed

NAIC Company Code

ADDITIONAL INFORMATION REQUIRED

(1.2) Other Affiliates: Subsidiaries

(2.2) (3.2) (4.2) (5.2) (7.11) (7.12) (7.13) (7.14) (7.2) (9.1) (9.2)

Noncontrolled Assets: Subsidiaries Guarantees for Affiliates: Subsidiaries Contingent Liabilities: Subsidiaries Long Term Leases: Subsidiaries Total Affiliated Investments: Company Less Affiliated Common Stock: Company Less Affiliated Preferred Stock: Company Net Affiliated Investments: Company Affiliated Investments: Subsidiaries Surplus Notes: Company Surplus Notes: Subsidiaries

(10.11) Capital Paid In: Company (10.12) Surplus Paid In: Company (10.13) Total Current Year's Capital Contributions: Company (10.2) Current Year's Capital Contributions: Subsidiaries

Source Subsidiaries' Life Risk-Based Capital LR033 Summary for Affiliated Investments Column (1) Line (13); Property and Casualty Risk-Based Capital PR004 Summary For Subsidiary, Controlled and Affiliated Investments for Cross-Checking Statement Values Column (1) Line (7) and Line (15) Subsidiaries' Life Risk-Based Capital LR014 Off-Balance Sheet Items Column (1) Line (11) Subsidiaries' Life Notes to Financial Statements #6e; Property and Casualty Notes to Financial Statements #5e Subsidiaries' Life Notes to Financial Statements #17a; Property and Casualty Notes to Financial Statements #10a Subsidiaries' Life Notes to Financial Statements #18; Property and Casualty Notes to Financial Statements #11 Company's Annual Statement Five-Year Historical Data Page 23 Column 1 Line 43 Company's Annual Statement Five-Year Historical Data Page 23 Column 1 Line 41

(1) Statement Value

Company's Annual Statement Five-Year Historical Data Page 23 Column 1 Line 40 Lines (7.11) - (7.12) - (7.13) Subsidiaries' Life Annual Statement Five-Year Historical Data Page 23 Column 1 Line 43 Less Lines 40 and 41; Property Company's Annual Statement Page 3 Column 1 Line 32 Subsidiaries' Life Annual Statement Page 3 Column 1 Line 32; Property and Casualty Annual Statement Page 3 Column 1 Line 26A. Company's Annual Statement Page 4 Column 1 Line 43a Company's Annual Statement Page 4 Column 1 Line 44a Line (10.11) + Line (10.12) Subsidiaries' Life Annual Statement Page 4 Column 1 Lines 43a + 44a; Property and Casualty Annual Statement Page 4 Column 1 Lines 24a + 25a

Denotes items that must be manually entered on the filing software. Š 2000 National Association of Insurance Commissioners

LR030

6/30/2000


Company Name

Confidential when Completed

NAIC Company Code

SENSITIVITY TESTS - AUTHORIZED CONTROL LEVEL (1) Sensitivity Tests Affecting Authorized Control Level Risk-Based Capital (1.1) Other Affiliates: Company (1.2) Other Affiliates: Subsidiaries

Source

Statement Value

LR033 Summary for Affiliated Investments Column (1) Line (12) LR030 Additional Information Required Column (1) Line (1.2)

LR014 Off-Balance Sheet Items Column (1) Line (11) LR030 Additional Information Required Column (1) Line (2.2)

(3.1) Guarantees for Affiliates: Company (3.2) Guarantees for Affiliates: Subsidiaries (3.99) Total Guarantees for Affiliates

LR014 Off-Balance Sheet Items Column (1) Line (20) LR030 Additional Information Required Column (1) Line (3.2)

(4.1) Contingent Liabilities: Company (4.2) Contingent Liabilities: Subsidiaries

LR014 Off-Balance Sheet Items Column (1) Line (21) LR030 Additional Information Required Column (1) Line (4.2)

0.700

0.020 0.020 0.020 0.020 0.020 0.020 0.020 0.020

(4.99) Total Contingent Liabilities

0.020 LR014 Off-Balance Sheet Items Column (1) Line (22) LR030 Additional Information Required Column (1) Line (5.2)

0.030 0.030

(5.99) Total Long-Term Leases

(7.2) Affiliated Investments†: Subsidiaries (7.99) Total Affiliated Investments

(4) Authorized Control Level After Test

0.700

(2.1) Noncontrolled Assets - Company (2.2) Noncontrolled Assets Subsidiaries (2.99) Total Noncontrolled Assets

(7.1) Affiliated Investments†: Company

Additional RBC

(3) Authorized Control Level Before Test

0.700

(1.99) Total Other Affiliates

(5.1) Long-Term Leases: Company (5.2) Long-Term Leases: Subsidiaries

(2) Additional Sensitivity Factor

0.030 LR030 Additional Information Required Column (1) Line (7.14) LR030 Additional Information Required Column (1) Line (7.2)

0.100 0.100 0.100

Excluding affiliated preferred and common stock Denotes items that must be manually entered on the filing software.

© 2000 National Association of Insurance Commissioners

LR031

6/30/2000


Company Name

Confidential when Completed

NAIC Company Code

SENSITIVITY TESTS - TOTAL ADJUSTED CAPITAL (1) Sensitivity Tests Affecting Total Adjusted Capital (8.1)

Dividend Liability: Company

(8.2)

Dividend Liability: Subsidiaries

Source

Statement Value

LR027 Calculation of Total Adjusted Capital Column (1) Line (3) + Line (4) LR027 Calculation of Total Adjusted Capital Column (1) Line (6)

Surplus Notes: Company

(9.2)

Surplus Notes: Subsidiaries

(2)

(3)

(4)

Change to Total Adjusted Capital

Total Adjusted Capital Before Test

Total Adjusted Capital After Test

-0.250 -0.250

(8.99) Total Dividend Liability (9.1)

Additional Sensitivity Factor

-0.250 LR030 Additional Information Required Column (1) Line (9.1) LR030 Additional Information Required Column (1) Line (9.2)

-1.000 -1.000

(9.99) Total Surplus Notes

-1.000

(10.1) Current Year Capital Contribution: Company (10.2) Current Year Capital Contribution: Subsidiaries (10.99) Total Current Year Capital Contributions

LR030 Additional Information Required Column (1) Line (10.13) LR030 Additional Information Required Column (1) Line (10.2)

-(11.1) Tax Sensitivity Test TAC -(11.2) Tax sSensitivity Test TAC

LR027ADJ Lines 11.1 + 11.2 LR027ADJ Lines 12.1 + 12.2

-1.000 -1.000 -1.000 -1.000 -1.000

Denotes items that must be manually entered on the filing software. Š 2000 National Association of Insurance Commissioners

LR032

6/30/2000


Company Name

Confidential when Completed

NAIC Company Code

SUMMARY FOR AFFILIATED INVESTMENTS

(1) (2) (3) (4) (5) (6) (7) (8) (9) (10) (11) (12) (13) (14)

Affiliate Affiliate Type Code Direct U.S. Property and Casualty Subsidiaries 1 Direct U.S. Life Subsidiaries 2 Indirect U.S. Property and Casualty Subsidiaries 3 Indirect U.S. Life Subsidiaries 4 Investment Subsidiaries 5 Holding Company in Excess of Indirect Subsidiaries 6 Alien Life Insurance Subsidiaries: Canadian 7 Alien Insurance Subsidiaries: Non-Canadian Life 8 Investment in Parent 9 Other Affiliate: Property and Casualty Insurers not 10 Subject to Risk-Based Capital Other Affiliate: Life Insurers not Subject to 11 Risk-Based Capital Other Affiliates 12 Publicly Traded Insurance Affiliates 13 Total (Sum of Lines (1) through (13) XXX

(1)

(2)

Statement Value

Book Value † XXX XXX XXX XXX XXX XXX XXX XXX XXX

(3) Difference Col. (1) - (2) XXX XXX XXX XXX XXX XXX XXX XXX XXX

XXX

XXX

X

0.300

=

XXX XXX

XXX XXX

X X X

0.300 0.300 0.225 XXX

= = =

XXX

(4) RBC Basis Subsidiaries' Total Risk-Based Capital After Covariance Subsidiaries' Total Risk-Based Capital After Covariance Subsidiaries' Total Risk-Based Capital After Covariance Subsidiaries' Total Risk-Based Capital After Covariance Subsidiaries' Total Risk-Based Capital After Covariance X 0.300 = Subsidiaries' MCCSR X 1.000 = X 0.300 =

Number of RBC Requirement Companies

If different than statement value. Denotes items that must be manually entered on the filing software.

© 2000 National Association of Insurance Commissioners

LR033

6/30/2000


Company Name

Confidential when Completed

NAIC Company Code

CROSSCHECKING FOR AFFILIATED INVESTMENTS Affiliated Preferred Stock (1)

(1) (2) (3) (4) (5) (6) (7) (8)

Schedule D Part 6 Section 1 Type Parent U.S. Propety and Casualty Insurer U.S. Life Insurer Alien Insurer Non-Insurer Which Controls Insurer Investment Subsidiary Other Affiliates Total (Sum of Lines (1) through (7))

Annual Statement Annual Statement Line Number Total Preferred Stock† 0199999 0299999 0399999 0499999 0599999 0699999 0799999

(2) Total from Life Risk-Based Capital Report‡

(3)

Difference

Affiliated Preferred Stock Check Total to Schedule D Summary Column 5 (9) Total

Line 39

Affiliated Common Stock (1)

(10) (11) (12) (13) (14) (15) (16) (17)

Schedule D Part 6 Section 1 Type Parent U.S. Propety and Casualty Insurer U.S. Life Insurer Alien Insurer Non-Insurer Which Controls Insurer Investment Subsidiary Other Affiliates Total (Sum of Lines (10) through (17))

Annual Statement Annual Statement Line Number Total Common Stock† 0999999 1099999 1199999 1299999 1399999 1499999 1599999

(2) Total from Life Risk-Based Capital Report§

(3)

Difference

Affiliated Common Stock Check Total to Schedule D Summary Column 2 (18) Total

† ‡ §

Line 53

Lines (1) through (8) and (10) through (17) come from Schedule D Part 6 Section 1 Column 6 of the annual statement. Lines (1) through (8) come from LR035 Details for Affiliated Investments Column (7). Lines (10) through (17) come from LR035 Details for Affiliated Investments Column (5). Denotes items that must be manually entered on the filing software.

© 2000 National Association of Insurance Commissioners

LR034

6/30/2000


Company Name

Confidential when Completed

NAIC Company Code

DETAILS FOR AFFILIATED INVESTMENTS

Affiliate Type Direct U.S. Property and Casualty Subsidiaries Direct U.S. Life Subsidiaries Indirect U.S. Property and Casualty Subsidiaries Indirect U.S. Life Subsidiaries Investment Subsidiaries Holding Company in Excess of Indirect Subsidiaries

Affiliate Code for Column (2) 1 2 3 4 5 6

RBC Basis Subs’ RBC After Covariance Subs’ RBC After Covariance Subs’ RBC After Covariance Subs’ RBC After Covariance Subs’ RBC After Covariance 0.300 x Statement Value

Affiliate Type Alien Insurance Subsidiaries - Canadian Life Alien Insurance Subsidiaries - Other Investment in Parents Other Affiliate - P&C Insurers not subject to RBC Other Affiliate - Life Insurers not subject to RBC Other Affiliate - All Other

(1)

(2)

(3)

(4)

Name of Affiliate

Affiliate Code (1 to 12)

NAIC Company Code or Alien ID Number†

Affiliate's RBC After Covariance‡

xxxxx

xxxxx

(5) Statement Value of Affiliate's Common Stock

(6) Total Value of Affiliate's Outstanding Common Stock

(7) Statement Value of Affiliate's Preferred Stock

Affiliate Code for Column (2) 7 8 9 10 11 12

RBC Basis Subsidiaries’ MCCSR 1.000 x Statement Value 0.300 x Statement Value 0.300 x Statement Value 0.300 x Statement Value 0.300 x Statement Value

(8) Total Value of Affiliate's Outstanding Preferred Stock

(9)

(10)

Percent Owned

RBC Requirement

xxxxx

xxxxx

(1) (2) (3) (4) (5) (6) (7) (8) (9) (10) (11) (12) (13) (14) (15) (16) (17) (18) (19) (20) (9999999) Total

† ‡

xxxxx

If applicable. If applicable. For Canadian life subsidiaries, the Minimum Continuing Capital and Surplus Requirement (MCCSR) should be used. Denotes items that must be manually entered on the filing software.

© 2000 National Association of Insurance Commissioners

LR035

6/30/2000


Follow-Up report on RBC tax 06-01-2001